
Glass. 
Book. 



COPYRIGHT DEPOSIT 



A TEXT-BOOK 

ON 

DISEASES OF 
THE EAR, NOSE 
AND THROAT 

BY 

CHARLES H. BURNETT, M.D. 
E. FLETCHER INGALS, M.D. 
JAMES E. N E W C O M B, M.D. 

IVITH NUMEROUS ILLUSTRATIONS 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 

I 9 o I 







THE LIBRARY OF 

CONGRESS, 
Two CoHitd Received 

SEP. 25 1901 

Copyright entry 
CLASS ^ XXc N'j. 

COPY a 



Copyright, 1901 

BY 

J. B. LippiNCOTT Company 



ELECTROTYPED AND PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U. 



PREFACE. 



The close relation between the diseases of the ear, nose, and throat 
has rendered it desirable that there should be a conjoint text-book on 
these diseases and their treatment. This work has therefore been di- 
vided into three parts, each written by a practical teacher specially 
familiar with the subject on which it treats. The aim of the authors 
has been to present the anatomy and physiology of the ear, nose, and 
^"^ ^at concisely, but with thoroughness and in accord with the latest 

^overies in their respective departments. 

In the treatment of the diseases of the ear, nose, and throat the 
authors believe that they have presented those methods of medication 
and surgery which are at once the newest and accepted as the best by 
the leading specialists in laryngology, rhinology, and otologj". Each 
author is, howe^'er, responsible for only his own statements. 

The editor desires to express his thanks to his associates for their 
prompt and untiring aid in the preparation of their parts of the work, 
thus enabling him to lay before the i^rofession a treatise that he be- 
lieves will be found helpful both to the general and the special prac- 
titioner of medicine and surgery, and particularly adapted to the needs 
of students by its concise and thorough presentation of the subjects 
within its scope. 

Charles Henry Burnett, 

Editor. 



ill 



CONTENTS. 



DISEASES OF THE EAR. 

BY CHARLES H. BURNETT, A.M., M.D. 

OF PHILADELPHIA. 



CHAPTER I. 

PAGE 

The Anatomy and Physiology of the Aukicee 1 



CHAPTER II. 

The Anatomy and Physiology of the Externaj. Auditory Canal 6 

CHAPTER III. 
The Anatomy and Physiology of the Membrana Tympani 16 

CHAPTER IV. 
The Anatomy ani:) Physiology of the Tympanic Cavity 24 

CHAPTER V. 

The Anatomy and Physiology of the Eustachian Tube and Mastoid 47 

CHAPTER VI. 

The Anatomy and Physiology of the Internal Ear and Auditory Xerve. . . 58 

CHAPTER VII. 
Instrumental Examination of the Ear 76 

CHAPTER VIII. 
Tests of Hk\ring 88 

CHAPTER IX. 

CiRCX'MSCRIBED AND DiFFUSE INFLAMMATION OF THE EXTERNAL AUDITORY CaNAL. 96 



VI CONTENTS. 



CHAPTEE X. 

PAGE 

Foreign Bodies in the External Ear 104 



CHAPTER XI. 

Results of Inflammation and Injuries of the External Auditory Canal . . . 112 



CHAPTER XII. 

Acute and Chronic Inflammation, Injuries, and Morbid Growths of the 

Membrana Tympani 121 



CHAPTER XIII. 
Acute Catarrhal Otitis Media 127 

CHAPTER XIY. 
Chronic Catarrhal Otitis Media 130 

CHAPTER XV. 

Treatment of Chronic Catarrhal Otitis Media 142 

CHAPTER XVI. 
Acute Purulent Otitis Media 158 

CHAPTER XVII. 
Chronic Purulent Otitis Media 175 

CHAPTER XVIII. 
Sequels of Chronic Purulent Otitis Media 194 

CHAPTER XIX. 

Otitic Extradural and Perisinous Abscesses 201 

CHAPTER XX. 
Otitic Phlebitis, Thrombosis, and Pyemia 205 

CHAPTER XXI. 

Otitic Cerebral and Cerebellar Abscess and Meningitis 212 



CONTENTS. vil 



DISEASES OF THE NOSE AND NASOPHARYNX. 

BY E. FLETCHER INGALS, A.M., M.D., 

OF CHICAGO. 
ASSISTED BY 

OTTO T. FREER, M.D., 

OF CHICAGO. 



CHAPTER I. 

PAGE 

Anatomy and Physiology of the Nose and Nasopharynx 221 



CHAPTER II. 
The Examination of the Nose and Nasopharynx 244 

CHAPTER III. 
Acute Rhinitis and Hay Fever 250 

CHAPTER IV. 

EpisTAXis AND Nasal Affections in Acute Infectious Diseases 265 

CHAPTER Y. 
Foreign Bodies in the Nose 273 

CHAPTER VI. 
Cutaneous Diseases, Deformities, and Injuries of the Nose 280 

CHAPTER VII. 
Fibrinous and Diphtheritic Rhinitis , 294 

CHAPTER VIII. 
Chronic Rhinitis, Simple and Intumescent 299 

CHAPTER IX. 
Hypertrophic and Atrophic Rhinitis 314 

CHAPTER X. 
Nasal Tumors 331 



Vlll CONTENTS. 



CHAPTEK XI. 

PAGE 

Syphilis and Tuberculosis of the Nose 349 



CHAPTER XII. 
Empyema of the Maxillary Antrum 359 

CHAPTER XIII. 
Inflammation of the Accessory Sinuses of the Nose 375 

CHAPTER XIV. 
Diseases of the Nasal Septum 391 

CHAPTER XV. 
Acute and Chronic Rhinopharyngitis , 413 

CHAPTER XVI. 
Hypertrophy of the Pharyngeal Tonsil 428 

CHAPTER XVII. 
Tumors of the Nasopharynx 445 

CHAPTER XVIII. 
Syphilis and Tuberculosis of the Nasopharynx 458 



DISEASES OF THE PHARYNX AND LARYNX. 

BY JAMES E. NEWCOMB, A.B., M.D., 

OF NEW YORK CITY. 



DISEASES OF THE PHARYNX. 

CHAPTER I. 
Anatomy and Physiology of the Pharynx 463 

CHAPTER II. 
Malformations and Deformities of the Pharynx 470 



CONTENTS. IX 



CHAPTER III. 

PAGE 

Acute Inflammations of the Pharynx 474 



CHAPTER lY. 
Chronic Inflammations of the Pharynx 479 

CHAPTER Y. 
Yascular Anomalies and Parasitic Diseases of the Pharynx 488 

CHAPTER YI. 

Tuberculosis, Lupus, and Syphilis of the Pharynx 496 

CHAPTER YII. 
Erysipelas, Herpes, Pemphigus, and Diabetic Ulcerations of the Pharynx.. 511 

CHAPTER YIII. 
Tumors of the Pharynx 516 

CHAPTER IX. 
Neuroses of the Pharynx 526 

CHAPTER X. 

Diseases of the Uvula and Tonsils 531 



DISEASES OF THE LARYNX. 

CHAPTER XL 
Anatomy and Physiology of the Larynx 576 

CHAPTER XII. 
Examination of the Larynx 589 

CHAPTER XIII. 
Acute Inflammations of the Larynx 598 

CHAPTER XIY. 
Chronic Inflammations of the Larynx 612 



X CONTENTS. 



CHAPTER XV. 

PAGE 

Tuberculosis of the Larynx 625 



CHAPTER XVI. 
Syphilis and Lupus of the Larynx 641 

CHAPTER XVII. 
Tumors of the Larynx 648 

CHAPTER XVIII. 
Neuroses of the Larynx 661 

CHAPTER XIX. 
Diphtheria \ 676 

CHAPTER XX. 

The Pharynx anu Larynx in the Exanthemata and other Fevers 693 

CHAPTER XXL 
Foreign Bodies in the Pharynx and Larynx 700 



LIST OF ILLUSTRATIONS, 



FIGURES. 

FIG. PAGE 

1. Surroundings of the first branchial cleft, and neighboring portions of the face 

of an embryo of one month ; left side magnified twelve diameters. (His 

and Schwalbe. ) 1 

2. Auricle of new-born male child. ( G. Schwalbe. ) 2 

3. Auricle of a woman. ( G. Schwalbe. ) 2 

4. Auricle of a man. ( G. Schwalbe. ) 3 

5. Right temporal bone of infant, outer surface, from photograph 6 

6. Inner surface of right temporal bone of infant, from photograph 6 

7. Inner surface of right temporal bone of infant, viewed directly from in front. . 7 

8. A, outer surface of the annulus tympanicus, left ear. (Politzer. ) 7 

8. B, Left tympanic ring of an infant turned forward upon its anterior limb and 

viewed from within. ( Gruber. ) 7 

9. Base of infant's skull, from photograph 8 

10. Vertical section through the right external auditory canal of a human embryo 

of seven months, natural size. (G. Schwalbe. ) 9 

11. Fully developed left temporal bone, outer surface 10 

12. Fully developed left temporal bone, inner surface 11 

13. Under surface of the left temporal bone. ( Gray. ) 12 

14. Vertical section of the external auditory canal, membrana tympani, and 

tympanic cavity, viewed from in front. (Politzer. ) 13 

15. The auricle and the cartilaginous part of the external auditory canal, left side. 

(Politzer. ) 14 

16. Base and squama of the left petrous bone, showing the inclination of the mem- 

brana tympani in the adult ; natural size, from photograph 17 

17. Left membrana tympani in position ; anterior wall of the osseous auditory 

canal cut away ; adult bone, from photograph 19 

18. Outer surface of the membrana tympani ; enlarged four diameters. ( Politzer. ) 19 

19. Left and right membran?e 20 

20. Quadrants of the membrana tympani and the membrana flaccida. (Sieben- 

mann. ) 20 

21. Inner surface of the right membrana tympani, with the malleus and incus 

attached to each other, enlarged three and one-half times. (Politzer. ) 21 

22. Pouches of the membrana tympani in their relation to the membrana flac- 

cida. ( Siebenmann. ) 22 

23. Cast of middle ear of new-born child, right side. (Siebenmann. ) 24 

24. Cast of middle ear of a child of nine months, outer surface. (Siebenmann. ). . 25 

25. A and B, right malleus : A, from in front ; B, from behind ; magnified four 

diameters. ( Henle. ) 26 

26. Ligamentous support of the ossicles, viewed from above. (Helmholtz. ) 28 

27. A and B, right incus; magnified four diameters. (Henle.) A, inner sur- 

face ; B, view in front 29 

xi 



XI I LIST OF ILLUSTRATIONS. 

FIG. PAGE 

28. A, B, and C, right stapes; magnified four diameters, (Henle. ) A, from 

within ; B, from in front ; C, from beneath 31 

29. Right tympanic cavity, viewed from ahove ; malleo-incudal and incudo-tym- 

panic joints ; magnified two diameters. (Henle. ) 32 

30. Partial view of left drum-cavity and aditus from in front ; the lowest portion 

of the cochlea, vestibule, and superior semicircular canal laid open by a 
vertical incision passing through the long axis of the latter. (Sieben- 
mann. ) 33 

31. Inner surface of the left membrana tympani (outer wall of tympanic cavity) 

and the attic, with the malleus head suspended in it. (Politzer. ) 34 

32. Diagrammatic representation of the formation of the so-called pouches of the 

membrana tympani 34 

33. Section through the long axis of the malleus at right angles to the membrana 

tympani, from an adult. (Brunner. ) 35 

34. Inner wall of the left tympanic cavity, natural size ; photograph from nature. . 36 

35. Posterior part of the inner tympanic wall, with the posterior wall partly dis- 

sected ; twice the natural size ; right ear. (Politzer. ) 37 

36. Left auditory apparatus, viewed from above ; tegmen tympani and upper part 

of the labyrinth removed ; natural size, from photograph. 39 

37. Cast of the soft parts of the middle ear, viewed from without ; the cartilagi- 

nous portion of the Eustachian tube is not included. ( Siebenmann. ) 40 

38. Nerve foramina at the fundus of the internal auditory canal. (Quain. ) 40 

39. Tympanic cavity after removal of the tegmen tympani and some of the bone 

anteriorly and interiorly ; course of facial nerve ; left side. (Politzer. ) 41 

40. Nerves in and about the tympanum. (Heath. ) 42 

41. Cast of the left middle-ear cavities, viewed from without. ( Siebenmann. ) 47 

42. Transverse section through the middle of the Eustachian tube, slightly magni- 

fied. ( Siebenmann. ) 49 

43. Diagrammatic section through the Eustachian tube, the muscles and fasciae. 

( Weber-Liel. ) 51 

44. Transverse section through the Eustachian tube at its lower end ; slightly 

magnified. (Siebenmann. ) 52 

45. Mastoid cells, left side, viewed from behind. (C. J. Blake. ) 54 

46. Auditory apparatus, left side, viewed from above, after removal of the tegmen 

tympani and upper half of the labyrinth ; natural size, from photograph ... 55 

47. Cast of the left middle ear ; view of inner surface of the cast shown in Fig. 41. 

(Siebenmann. )..... 56 

48. External view of a cast of the left labyrinth. ( Henle. ) 60 

49. Section through the osseous capsule and the modiolus of the cochlea, with the 

lamina spiralis ossea. (Politzer. ) 61 

50. Section through the lower turn of the cochlea of a new-born infant. (Polit- 

zer. ) 64 

51. Transverse section of the organ of Corti ; magnified eight hundred diameters. 

( Waldeyer. ) 66 

52. Section through the osseous and membranous semicircular canals. (Polit- 

zer. ) 70 

53. Horizontal section through the left auditory apparatus, viewed from above ; 

photographed from nature 73 

54. Profile view of the left tympanum and part of the internal ear, from before 

and somewhat from above, the anterior part having been cut away ; magni- 
fied four times. ( After Quain. ) 74 

55. Forehead electric lamp in position 76 



LIST OF ILLUSTRATIONS. XIU 

FIG. PAGE 

56. Hand otoscope (one-half natural size) 76 

57. Illumination of the ear by means of the forehead-mirror during insufflation of 

a powder 77 

58. Gruber's aural specula 78 

59. Burnett's modification of Siegle's pneumatic otoscope 79 

60. Forceps for removing foreign bodies from the ear 80 

61. Cotton-holder 81 

62. Eustachian catheter 82 

63. Auscultation-tube 83 

64. Hand inflation-bag in the Eustachian catheter 83 

65. Vertical section of the nasopharynx, with the catheter introduced into the 

Eustachian tube, right side 85 

66. Politzer's air-bag for inflating the middle ears (one-third natural size) 86 

67. Inflation of the tympana by Politzer's air-bag 87 

68. Clinical tuning-fork 90 

69. Aspergillus mycelium 101 

70. Formation of aspergillus fruit-stalks 101 

71. Fully developed aspergillus fruit-stalk and head 101 

72. Hook for removal of a foreign body from the ear 110 

73. Removal of a foreign body from the external ear. ( AV. B. Dalby. ) 110 

74. Sexton's foreign-body forceps (two-thirds natural size) Ill 

75. Cast of the left temporal bone after corrosion of the osseous tissue. (Sieben- 

mann. ) 151 

76. Partly diagrammatic vertical section of the left auditory apparatus, in front of 

malleus and oval window, running through the vestibule and promontory, 
and viewed from in front. (Modified from Siebenmann. ) 152 

77. Instruments for ossiculectomy 156 

78. Nervous connection between the teeth and the ear. ( Woakes. ) 159 

79. Paracent€sis-knife 162 

SO. Inner surface of membrana tympani, right side 173 

81. Outer surface of a normal membrana tympani, left side ; magnified three and 

a half diameters. (Politzer. ) 177 

82. Tympanic syringe 180 

83. Polypus snare 187 

84. Polypus hook 187 

85. Tweezer forceps 188 

■86. Cast of the middle ear and mastoid, seen from without. ( F. Siebenmann. ) . . 207 

87. Framework of the external nose. (Zuckerkandl. ) 222 

88. View of the nasal septum. X I- ( Heymann, after Mihalkovics. ) 224 

■89. Lateral wall of the nose ; sounds lying in the lachrymonasal duct and in the 

cavity of the sphenoid. X f • (Heymann, after Mihalkovics. ) 227 

90. Transverse section through the posterior portion of the nasal cavity. (Zucker- 

kandl.) ' 229 

91. Lateral wall of the nose ; the middle and inferior turbinates are removed. 

(M. Schmidt, after Merkel. ) 230 

92. Horizontal section of the face through the ethmoid region. X f- (Hey- 

mann and ^lihalkovics. ) 231 

93. The outer wall of the nasal fossa removed and the lachrymal duct opened its 

entire lengtb. (Stoerk. ) 232 

94. Section through normal mucous membrane of the middle turbinal. showing 

epithelium and connective tissue beneath. (Schiefferdecker. ) 234 

95. Olfactory supporting cells. (Heymann, after Schiefferdecker. ) 236 



XIV LIST OF ILLUSTRATIONS. 

FIG. PAGE 

96. Transverse section through the olfactory mucous membrane of a man of 

thirty. (Heymann, after von Braun. ) 237 

97. The muscles of the soft palate, posterior view. ( Bresgen. ) 241 

98. Transverse section of the pharyngeal tonsil of a one-year-old child. (Hey- 

mann. ) 243 

99. Ingals's nasal speculum (three-fifths natural size) 244 

100. Position for posterior rhinoscopy 246 

101. Posterior nares. ( M. Schmidt. ) 247 

102. Freer's nasal irrigating tube 258 

103. Ehinoscopic image in rhinoscleroma. (Stoerk. ) 284 

104. Both choanse narrowed by semicircular folds and membranes. (Stoerk.)... 285 

105. Bacillus of rhinoscleroma. (M. Schmidt. ) 286 

106. Powder-blower for the nose 309 

107. Flat nasal probe (two-fifths natural size ) 310' 

108. Ingals's cautery electrodes (two-fifths natural size) 311 

109. Hypertrophy of the posterior ends of the inferior turbinated bodies ........ 314 

110. Polypoid swelling on the posterior free end of the middle turbinate. ( Stoerk. ) 314 

111. Bilateral hypertrophic swelling of mucous membrane of septum. (Stoerk.) 315 

112. Thickening of mucous membrane of septum. (Stoerk. ) 316 

113. Left nasal fossa, showing polypoid thickening of turbinals. (Bresgen.) .... 317 

114. Ingals's nasal scissors (one-third natural size) 319 

115. Nasal trephines. ( Modification by Curtis. ) 320 

116. Nasal burrs 320 

117. Right nasal fossa. Atrophy of mucous membrane and turbinated bones. 

(Zuckerkandl. ) 323 

118. Metaplasia of cylindrical epithelium of nasal mucosa to pavement epithelium. 

(Stoerk. ) 323 

119. Section of entire thickness of mucous membrane in atrophic rhinitis. 

(Stoerk. ) 324 

120. Bacillus of oza^na. (M. Schmidt. ) 325 

121. Screw applicator for Gottstein's tampon 328 

122. Right nasal fossa, showing polypi. ( Bresgen. ) 332 

123. Section of polypus. ( Heymann. ) 333 

124. Mucosa of middle turbinal of an eight-year-old girl, showing papillary 

change preliminary to the formation of mucous polypi. (Heymann. ) . . . . 334 

125. Mcintosh cautery snare 336 

126. Hypodermic syringe with long silver nozzle (one-half natural size) 337 

127. Cotton applicator made of copper (two-fifths natural size) 338 

128. Papillary tumors of the nose on the middle and lower turbinals. (Hey- 

mann. ) 339 

129. Ingals's nasal dressing forceps (three-fifths natural size) 353 

130. Changes in the second stage of chronic empyema of the antrum of High- 

more. (Heymann. ) 361 

131. Ingals's electric lamp for transillumination (one-half natural size) 364 

132. Vohsen's transillumination lamp 365 

133. Krause's trocar 366 

134. Transverse section through the antrum of Highmore. (Heymann. ) 367 

135. Dental cyst entering the antrum of Highmore. (Heymann. ) 368 

136. Lateral nasal wall. ( Heymann. ) 369 

137. Lateral wall of nose. (Heymann. ) 370 

138. Lateral nasal wall after removal of middle turbinal. (Heymann. ) 371 

139. Ingals's drainage-tube for antrum 372 



LIST OF ILLUSTRATIONS, XV 

TIG. PAGE 

140. Cysts and polypi in the antrum of Highmore. ( Heymann, after Luschka. ) . 372 

141. Probing the frontal sinus. (Heymann, after Lichtwitz. ) 378 

142. Palmer's frontal sinus drill 380 

143. Ingals's frontal sinus drainage-tube 381 

144. Probe passed into sphenoidal sinus through natural opening. (Lichtwitz.) 384 

145. Spoon-shaped probe for entrance into sphenoidal sinus. (Max Schaffer. ). . . 385 

146. Bone-forceps for opening sphenoidal sinus. (Max Schaffer. ) 386 

147. Transverse section through nasal cavity. (Bresgen. ) 392 

148. Deflection of anterior portion of septum in the right naris, with hypertrophy 

of the anterior end of the lower turbinal in the left 393 

149. Gleason's operation 397 

150. Roberts's operation 399 

151. Ingals's submucous cartilage knife (one-half natural size) 400 

152. Sajous's knife (one-half natural size) 400 

153. Ingals's septum knife (two-fifths natural size) 400 

154. Ingals's spud ( one-half natural size) 401 

155. Ingals's nasal saw ( one-half natural size) 401 

156. Sharp and Smith's adjustable nasal saw (one-half natural size) 401 

157. Ingals's septum forceps 402 

158. Ingals's heavy bone-scissors (one-third natural size) 402 

159. Ingals's nasal spatula (one-half natural size) 403 

160. Ingals's nasal bone-forceps (one-half natural size) 406 

161. Adenoid tissue at vault of pharynx. ( Luschka. ) 419 

162. Pharyngeal bursa. (Luschka. ) 419 

163. Rhinoscopic image of an enlarged Luschka's tonsil. (Heymann. ) 430 

164. Adenoid vegetations hiding the upper part of the choana? 431 

165. Gottstein's ring-knife 439 

166. Mackenzie's modification of Lowenberg's forceps 442 

167. Allingham's mouth-gag (one-half natural size) 442 

168. Fibrosarcoma of the postnasal space of a seventeen-year-old youth. (Miku- 

licz and Michelson. ) 448 

169. Ingals's postnasal snare applicator for tumors in nasopharynx (one-third 

natural size) 451 

170. Retronasal fibromucous tumor 454 

171. Round-celled sarcoma of nasal cavity and nasopharynx. (Stoerk. ) 455 

172. Side view of muscles of the pharynx. (Gray and Browne. ) 464 

173. Method of depressing the tongue for examining the pharynx and for pos- 

terior rhinoscopy. ( Bosworth. ) 468 

174. Tongue-depressors 469 

175. Congenital pouch and atresia of the pharynx. (Lennox Browne. ) 470 

176. Pouch of the pharynx in advanced life. (Lennox Browne. ) 470 

177. Separate mucous investment of the palatoglossus muscle on each side. 

( Bosworth. ) 472 

178. Follicular pharyngitis, with adherence of pillars to faucial tonsils. (Kyle.). 482 

179. Large follicles on pharyngeal wall. ( Kyle. ) 482 

180. Pharyngitis granulosa. (Seifert and Kahn. ) 483 

181. Retropharyngeal abscess, phlegmonous variety. (Bosworth. ) 486 

182. Ascending pharyngeal arteries of abnormal size. ( Farlow. ) 488 

183. Oidium albicans. ( Bresgen. ) 492 

184. Buccal secretion ; microscopic appearance. XYon Jaksch and Cagny.) 493 

185. Pharyngeal tuberculosis. ( Chappell. ) 499 

186. Tuberculosis of the uvula. (Lennox Browne. ) 500 



XVI LIST OF ILLUSTRATIONS. 

FIG. t>AGE 

187. Lupus of the soft palate. ( McBride. ) 502 

188. Adhesion of uvula to faucial pillars ; ulcer in left tonsil. (Lennox Browne. ). 506 

189. Active tertiary ulceration of the pharynx, with old scar formation. (Lennox 

Browne. ) 507 

190. Ulceration of velum in congenital syphilis. (Lennox Browne. ) 510 

191. Papilloma of the soft palate. ( Bosworth. ) , 516 

192. Papilloma of the uvula. (Seifert and Kahn. ) 517 

193. Fibroma of the soft palate. (Seifert and Kahn. ) 517 

194. Lymphosarcoma of tonsil. (Seifert and Kahn. ) 521 

195. Paralysis of left side of palate. (Bosworth. ) 529 

196. Operation of uvulotomy. ( Bosworth. ) 534 

197. Sajous's uvulotome 535 

198. Seiler's uvula scissors 535 

199. Right supratonsillar fossa, with plica pulled forward and upward. ( Paterson. ) 537 

200. Development of the tonsil. ( Retterer. ) 539 

201. Acute lacunar tonsillitis. (Griinwald. ) 543 

202. Acute croupous tonsillitis. ( Griinwald. ) 548 

203. Acute ulcerative tonsillitis. ( Moure. ) 549 

204. Circumtonsillar suppuration. ( Griinwald. ) 552 

205. Leland's tonsil knife 554 

206. Lingual varix. ( After Lewin. ) 556 

207. Hypertrophy of the faucial tonsil. (Seifert and Kahn. ) 559 

208. Set of tonsil instruments (Makuen's) 562 

209. Mackenzie's tonsillotome 562 

210. Mathieu's tonsillotome. (Ermold model. ) 563 

211. Ermold's tonsillotome 563 

212. Butts's tonsillar hsemostat 566 

213. Farlow's tonsil snare 567 

214. Schech's universal handle for galvano-caustic operations in the pharynx, 

nose, and larynx 568 

215. Wright's electric amygdalotome 569 

216. Wright's electric tonsil snare 569 

217. Hypertrophy of the lingual tonsil. (McBride. ) 571 

218. Hypertrophy of the lingual tonsil. (Seifert and Kahn.) 571 

219. Myles's lingual tonsillotome 572 

220. Polypoid hypertrophy of the tonsil. (Lemariey. ) 572 

221 . Front view of the larynx, thyroid cartilage in position. ( Browne. ) 578 

222. Side view of the larynx. ( Browne. ) 578 

223. Side view of the larynx, showing the interior, the right plate of the thyroid 

cartilage being removed. ( Browne. ) 579 

224. The cricoid cartilage, the arytenoid cartilages, and the cartilages of Santo- 

rini. (H. Allen) 579 

225. The hyoid bone and larynx, with ligaments, seen from in front. (H. Allen. ) 581 

226. The same, seen from the side. ( H. Allen. ) 581 

227. The rima glottidis. (H. Allen. ) 582 

228. Side view of the larynx, showing the left ventricle of Morgagni, left epi- 

glottic ligament, etc. ( Browne. ) 583 

229. View of the larynx opened from behind. (Browne. ) 583 

230. Arterial supply of the larynx, posterior view, showing the distribution of the 

superior laryngeal artery. ( Bosworth. ) 584 

231. Arterial supply of the larynx, anterior view, showing the distribution of the 

inferior laryngeal artery. (Bosworth. ) 585 



LIST OF ILLUSTRATIONS. Xvii 

FI<5- PAGE 

232. Course of the laryngeal branches of the vagus nerve in the new-born. 

(Henle. ) 586 

233. Side view of the larynx, showing right cricothyroid muscle. (Browne.). . . 586 

234. Muscles of the larynx, seen from behind. (Browne. ) 587 

235. Side view of the larynx, showing interior of the left half. (Browne.) 587 

236. Mackenzie's gas-bracket 589 

237. The Phillips photophore 590 

238. Shade and condenser 590 

239. Pomeroy's head-mirror 591 

240. Throat-mirrors 591 

241. Diagram showing the principle of laryngoscopy. (Bosworth. ) 592 

242. Diagrammatic view of the laryngoscopic reflection. (Schrotter.) 592 

243. Kirstein's laryngoscope with electric-light attachment and interchangeable 

depressor. (Thorner. ) 593 

244. Position of neck and head during examination with the electric orthoscope 

or autoscope. (Thorner. ) 594 

245. Freudenthal's electric lantern for translumination of the larynx 594 

246. Laryngeal image during breathing and at the beginning of phonation. ( Bres- 

gen. ) 595 

247. Acute laryngitis. (Krieg. ) 598 

248. Rugie of interarytenoid space simulating ulceration in simple laryngeal 

catarrh. (J. D. Arnold. ) 599 

249. Hemorrhagic laryngitis. (Krieg. ) 600 

250. Subglottic ccdema. (J. S. Cohen. ) 600 

251. Early stages of tedema. ( Krieg. ) 609 

252. A and B, perichondritis cricoidea and arytfenoidea. (Rosenthal. ) 623 

253. Tubercular infiltration of the larynx. (Griinwald. ) 627 

254. Section through the right aryepiglottic ligament. (Rosenthal. ) 628 

255. Tuberculosis of the larynx. (Seifert and Kahn. ) 629 

256. Tubercular infiltration and ulceration of the larynx. ( Griinwald. ) 630 

257. Diffuse tuberculous infiltration of the entire larynx, and tuberculous tumor 

formation. ( Griinwald. ) 630 

258. Thickening of the epiglottis and arytenoid cartilages ; disease at left apex ; 

subject of tuberculous laryngitis. (Lennox Browne. ) 632 

259. Heryng's laryngeal knives and curettes 639 

260. Mackenzie's laryngeal forceps 649 

261. Dundas Grant's guarded forceps 650 

262. Mathieu's laryngeal snap-guillotine 650 

263. Papilloma of the vocal cord as usually seen. (Lennox Browne. ) 651 

264. Papilloma covering the laryngeal aperture and attached anteriorly. 

(Griinwald. ) 651 

265. Carcinoma of the larynx. ( Griinwald. ) 654 

266. Stoerk's forceps 658 

267. Schrotter' s tube forceps, with knives and applicator 659 

268. Bilateral paralysis of superior laryngeal nerve. (Porcher. ) 668 

269. Right recurrent paralysis ; position of cords in deep inspiration. (Porcher. ). 669 

270. Bilateral recurrent laryngeal paralysis. (Porcher. ) 669 

271. Paralysis of the interarytenoideus muscle. (Porcher. ) 671 

272. Unilateral adductor paralysis ; position of the cords in attempted phonation. 

(Porcher. ) 671 

273. Bilateral abductor paralysis ; position of the cords in deep inspiration. 

(Porcher. ) .^ 672 

B 



XVIU LIST OF ILLUSTRATIOJiTS. 

riG. PAGE 

274. Paralysis of right internal tensor. (Porcher. ) 673 

275. Ermold's antitoxin syringe 689 

276. O'Dwyer intubation set 690 

277. Bond's forceps ( Eoe's modification) 702 

278. Fauvel's forceps, antero-posterior view 703 

279. Dawson's flexible forceps 704 

280. Gross's bristle probang.- 704 

281. Mackenzie's laryngeal forceps 707 

282. Cusco's laryngeal forceps 707 



PLATES. 

PLATE PAGE 

I. Membranous labyrinth of the right side, seen from within, above, and 

behind. ( F. Siebenmann. ) 60 

II. Horizontal section through the right cochlea, striking the vestibular end 
and the cupola, but avoiding the modiolus of the middle whorl. (F. 
Siebenmann. ) 62 

III. Burnett's mounting of the Chevalier Jackson pneumatic masseur, fitted 

with the modified Siegle pneumatic otoscope 144 

IV. Facial paralysis caused by acute purulent otitis media tuberculosa. (C. H. 

Burnett.) 194 

V. Facial paralysis occurring in the course of chronic purulent otitis media. 

(C. H. Burnett. ) 195 

VI. Diagram of intra- and extracranial venous anastomosis. ( Mace wen. ) 206 

VII. A section through the mucosa and bone on the inner surface of the lower 

turbinal. (Heymann. ) 234 

VIII. Median section of the head and neck. (Quain, after Braune.) 464 

IX. View of the soft palate and isthmus faucium from before. (Quain, after 

J. Symington. ) 465 

X. Lupus vulgaris of the palate and fauces and of the larynx. (Chiari and 

Riehl. ) ". 502 

XI. Syphilis of the larynx. (J. Schnitzler. ) 642 

XII. Syphilis of the larynx. ( J. Schnitzler. ) 644 

XIII. Colonies of diphtheria and pseudodiphtheria bacilli 678 

XIV. Diphtheria, pseudodiphtheria, and streptococci and diplococci associated 

in a culture of pseudodiphtheria 686 



DISEASES OF THE EAR. 

BY CHARLES H. BURNETT, A.M., M.D., 

Clinical Professor of Otology in the AVoman's Medical College of Pennsylvania. 



Fig. 1. 



CHAPTEE I. 

THE AXATOMY AND PHYSIOLOGY OF THE AFRICLE. 

Embryology. — The auricle, or pinna, and the external auditory canal 
are formed about the first external branchial furrow. They belong, there- 
fore, in their development not only to 
the inferior maxillary process of the 
mandibular arch, but also to the an- 
terior i^ortion of the hyoidal arch, 
where it borders on the j)osterior boun- 
dary of the first branchial furrow. The 
tumid edges surrounding the first ex- 
ternal branchial furrow show a ten- 
dency to divide into a number of hil- 
locks — the so-called auricular hillocks 
of Moldenhauer — about the end of the 
first month of embrj'onal life. 

His describes six of these promi- 
nences. Two of them belong to the 
inferior mandibular arch and bound 
the anterior edge of the branchial fur- 
row (Fig. 1, 1 and 2), and three are 
parts of the hyoidal arch, and are 
found along the posterior edge of the 
branchial furrow (Fig. 1, 4-6) » Be- 
tween these two rows, at the ui)per end 
of the branchial furrow, is found the 

so-called third hillock (Fig. 1, 3), or the tuberculum intermedium of His. 
Hillock ^N'o. 1 (Fig. 1, 1) of the mandibular arch gives off a small acces- 
sory hillock that participates as the tuberculum tragicum in the forma- 
tion of the auricle, while the rest of the x^rimary hillock region over- 




Surroundings of the first branchial cleft, 
and neighboring portions of the face of an 
embryo of one month; left side magnified 
twelve diameters. (His and Schwalbe.) 1-6, 
His's auricular prominences ; 1, tuberculum 
tragicum ; 2, tuberculum anterius ; 3, tuber- 
culum intermedium ; 4, tuberculum anthe- 
licis ; 5, tuberculum antitragicum ; 6, region 
of the lobule ; I, auditory vesicle ; c, His's 
cauda helicis, or free aural fold of Schwalbe ; 
helix hyoidalis of Gradenigo. Between the 
hillocks is the fossa angularis. 



DISEASES OF THE EAR. 



arches to some extent hillock No. 6 (Fig. 1, 6) and unites with it. The 
free portion of hillock Xo. 6 develops into the lobule of the auricle. 
Behind the three hillocks 4, 5, and 6 of the hyoidal arch originates a 
parallel ridge that becomes the cauda helicis of His. The second hillock, 
or tubercle No. 1, forms the tragus, hillock No. 5 the antitragus, hillock 
No. 2 the cms helicis, and hillock No. 3 and the cauda unite to form the 
complete helix. The fourth hillock, the tuberculum anthelicis, finally 
forces itself forward within the helix and becomes the anthelix. 

The furrow bounded by the auricular hillocks and extending in a 
dorso-ventral direction, with indentations between every two hillocks, is 
called by His the fossa augularis (Fig. 1). A transverse ridge, the central 
tubercle, in about the middle of its course, divides the fossa angularis 
into an upper and a lower portion, the latter finally deepening into the 
concha proper and the external auditory canal. 

The Developed Auricle. — Fig. 2 represents the auricle of a new-born male 
child, with converging hairs on the highly develox)ed Darwinian ear-point. 

3 shows the auricle of a 



Fig. 3. 




Auricle 



of a woman. 
Schwalbe.) 



Fig. 

woman with well-marked Dar- 
winian ear-point. Fig. 4 shows 
the auricle of an adult man, 
with the Darwinian ear-point at 
c. This latter part in the auricle 
of man corresponds to the pointed 
ear of the lower animals. The 
auricle consists of a fold of the 
skin of the face reflected over a 
shell-shaped cartilaginous sup- 
port, the various convolutions and 
surfaces of which it closely and 
tightly follows, passing inward 
with it into the cartilaginous part 
of the external auditory canal. 
The cartilaginous framework of 



Auricle of a new- 
born male child. (G. 
Schwalbe. ) 

the human auricle extends inward 
at the concha into the porus acusticus externus of the temporal bone, and 
is united to the free outer edge of the osseous external auditory canal. 
It thus forms about one-third of the external auditory canal, the inner 
two-thirds being formed of bone. The cartilage of the auricle is further- 
more held in place by ligaments and delicate muscles. Over the whole 
is reflected the aforesaid skin of the face, passing inward to line the 
external auditory canal as a dense, sensitive cutaneo-periosteal tissue, 
but extending over the outer surface of the membrana tympani simply 
as its very thin outer or dermoid layer. The outer surface of the auricle 
is, on the whole, a concave surface, whereas the surface turned towards, 
the side of the head is convex. 



THE ANATOMY AND PHYSIOLOGY OF THE AURICLE. 



The ligaments of tlie auricle are two in number, — viz., the anterior 
ligament of Valsalva, running from the root of the zygoma to the helix 
and tragus, and the posterior ligament, from the anterior part of the 
outer surface of the mastoid to the emi- 
nentia conchse. 

The muscles of the auricle consist 
of two sets, — viz., (1) those that arise 
from the vicinity of the external ear 
and are inserted into the auricle, and 
(2) those that originate from and 
terminate in the cartilage. 

Sl-ui of the Auricle. — The skin on 
the convex surface of the auricle is so 
connected by elastic fibres to the carti- 
lage as to be somewhat movable upon 
the latter. On the concave or anterior 
surface the skin is bound firmly and 
immovably to the perichondrium. 
The distribution of fat also varies 
greatly. In the cymba concha, in the 
deepest i^ortions of the concha propria, 
on the lower crus helicis, the apex of 
the fold of the anthelix, and inner sur- 
face of the tragus fat is entirely absent. 
There is, however, a sparse distribution 
of fat on both slopes of the fold of the 
anthelix in the fossa navicularis, the 
fossa triangularis, and in the rest of the 
territory of the concha i)ropria. How- 
ever, the subcutaneous connective tissue 
of the convex surface contains numer- 
ous fat racemes. Fat is especially 
abundant in the lobule. The epidermis 
and cutis of the convex surface of the 
auricle are similar to those of the neigh- 
boring integument. 




Auricle of a man. (G. Schwalbe.) ab, 
auricular base ; ahc, auricular triangle ; c, 
Darwinian point ; 1, crus helicis ; 2, 2, as- 
cending anterior upper helix ; 3, descending 
posterior helix ; 4, lobule of the auricle ; 5, 
trunk of the anthelix ; 6, inferior crus of the 
anthelix ; 7, superior crus of the anthelix ; 
8, antitragus ; 9, tragus ; 10, supratragic tu- 
bercle ; 11, anterior sulcus of the auricle (in- 
cisura tragohelicina) ; 12, Intertragie in- 
cisure ; 13, retrolobular tubercle of His ; 14, 
posterior sulcus of the auricle (incisura ant- 
helicis) ; 15, helicolobular sulcus ; 16, supra- 
lobular sulcus ; 17, fossa navicularis, or sca- 
phoidea ; 18, fossa triangularis ; 19, cymba 
conchse ; 20, cavity of the concha ; 21, retro- 
lobular sulcus. 



Delicate hairs with 
accomi^anying sebaceous glands, as well as small sweat-glands, are scat- 
tered over this surface. On the concave surface the skin is much more 
delicate, and the epidermis very thin. Papillary elevations in the cutis 
are few and low, and in some places scarcely discernible. Delicate hairs 
are found in those regions in which there is a deposit of fat. The hairs 
on the tragus, antitragus, and incisura intertragica are especially long 
in the male of advanced age. Associated with the hairs are sebaceous 
glands, well developed in the cavity of the concha. Comedones may 
form at these points. In the small plugs of sebum the so-called louse 



4 DISEASES OF THE EAR. 

of the hair-follicle is found. (Henle and Schwalbe.) Sweat-glands are 
wanting in the larger part of the concave surface of the auricle. At 
the entrance to the auditory canal modified sweat-glands occur as the 
ceruminous or ear-wax glands. 

Arteries and Veins. — The anterior auricular arteries originate from the 
superficial temporal, and the posterior auricular branches from the pos- 
terior auricular artery. The anterior auricular veins anastomose with the 
superficial temporal vein. The posterior auricular veins anastomose by 
means of a net-work of veins behind the ear, emptying chiefly into the 
external jugular vein, but to some extent also into the posterior facial 
vein. The veins of the under surface of the cartilaginous auditory canal 
anastomose with that part of the aforesaid venous net- work in communi- 
cation with the posterior facial. The veins of the auditory canal, the deep 
auriculars, originating from the bony canal and from part of the cartilagi- 
nous portion of the auditory canal, anastomose with the venous net be- 
hind the articular portion of the inferior maxilla. 

lA/m/phatics. — According to Sappey and G. Schwalbe, the lymphatics 
of the auricle originate close beneath the epidermis in the papillary eleva- 
tions of the cutis, the interpapillary spaces, and the neighborhood of the 
hair- follicles and sebaceous glands as a net- work of stellate and communi- 
cating lacunae, from which arises a net- work of communicating lym- 
phatic capillaries. From the latter originate the excretory lymphatics, 
which pass in three directions from the auricle, — viz., (1) the anterior lym- 
pMtics, from two to four in number, some passing from the concha and the 
external auditory canal and emptying into a lymphatic gland immedi- 
ately in front of the tragus, while others arise from the fossa triangularis 
and the ascending part of the helix, pass around the edge of the helix to 
the convex surface of the auricle, and empty into the mastoid glands ; 
(2) the posterior lymphatics, five in number, arising from the concave side 
of the auricle near the helix and anthelix ; these pass around the edge 
of the auricle and empty into the mastoid glands ; (3) the inferior lym- 
phatics, from seven to eight in number, are developed from the lobule 
of the auricle and are distributed to the lymphatics within the parotid, 
lying immediately beneath the external auditory canal. 

Nerves. — The motor nerves of the small auricular muscles arise en- 
tirely from the facial. The sensory nerves of the auricle arise from the 
anterior auricular branches of the auriculo-temporal nerve, and are dis- 
tributed to the skin of the tragus and ascending helix. The rest of the 
auricle and the lobule are supplied by branches of the auricularis magnus 
of the third cervical. I^euralgia of the auricle in caries of the cervical 
vertebrae may be explained by recalling the innervation of this part of 
the ear from the auricularis magnus. It is well to bear in mind that very 
often the auricularis magnus contains filaments from the spinal accessory 
nerve that participates in the formation of the cervical plexus. 

The facial branches of the auricularis magnus communicate with the 



THE ANATOMY AXD PHYSIOLOGY OF THE AUEICLE. 5 

facial nerve ; the posterior or auricular branches communicate with the 
auricular branches of the facial and pneumogastric, and the mastoid 
branches with the posterior auricular branch of the facial, and are dis- 
tributed to the skin behind the ear. 

The skin of the auditory canal is supplied by two branches of the au- 
riculo-temporal nerve, the so-called internal nerves of the auditory canal. 
They enter the canal at the junction of the cartilaginous with the osseous 
portion of the auditory canal, the upj)er one being distributed to the 
membrana tympani as the membrana tympani nerve. A twig of the 
auricular branch of the pneumogastric nerve passes to the posterior wall 
of the osseous auditory canal, while another twig of the auricular branch 
of the pneumogastric communicates with the posterior auricular branch 
of the facial nerve, and is distributed to the medial or convex surface of 
the auricle chiefly, but it also sends a twig directly through the cartilage 
to be distributed to the skin on the concave surface of the auricle. 

Eesoiumt Functions of the Auricle. — The function of the auricle in man 
is, when added to the cavity of the auditor}^ canal, that of a resonator 
adapted to augment just those high notes or sounds most likely to be of 
interest or importance to man. It is a foct that the auricle in combina- 
tion with the auditory canal, closed at the bottom by the membrana tym- 
pani, forms a resonator of more or less conical shape, the special function 
of which is to strengthen waves of sound i)Ossessing a short wave-length. 



CHAPTEE 11. 

THE ANATOMY AND PHYSIOLOGY OF THE EXTERNAL AUDITOEY 

CANAL. 

The temporal bone at birth consists of three distinct parts, — viz., the 
squama, the annulus tympanicus, and the petromastoid portion. The 

Fig. 5. 




I 

e f h 
Eight temporal bone of infant, outer surface, from photograph, a, squama ; h, c, natural dehis- 
cences in the young bone ; petrosquamous suture ; d, i, annulus tympanicus ; e, stylomastoid foramen ; 
/, stapes in the oval window; g, jugular fossa; h, carotid foramen; k, outer wall of attic, so-called 
"scute;" I, zygoma. 

squama (Fig. 5, a) and the petromastoid (Fig. 5, &, c-li) are the largest, while 
the small annulus tympanicus is applied to the outer side of the petrous 

Fig. 6. 




e f 
Inner surface of right temporal bone of infant, from photograph, a, inner surface of squama ; 
b, petrous pyramid; c, entrance to Eustachian tube; d, carotid canal; e, position of jugular bulb; 
/, entrance to aquseductus vestibuli ; g, lower back part of inner surface of pyramid ; h, porus acusticus 
internus ; i, subarcuate space beneath superior semicircular canal ; k, ridge of petrous pyramid ; I, 
petrosquamous suture. 

pyramid (Fig. 5, d-i). A view of the inner surface of the infant's tem- 
poral bone shows only two of these original parts, — the squama and the 



ANATOMY AND PHYSIOLOGY OF EXTERNAL AUDITORY CANAL. 



important i^etrosquamous pyramid (Fig. 6, a and &, e, /, I). A view of 
this same bone directly in front shows the three component parts of the 
bone in relation to one another, — the 

squama (Fig. 7, «, c), the annulus tym- Fig. 7. 
panicus (Fig. 7, e), and the petrous part 
(Fig. 7, g^ i, Jc, m). A closer inspection 
of Fig. 5 shows the outer surface of the 
squama («), its line of union with the 
petromastoid at h, c, its tympanic por- 
tion, or ''scute," at Z:, descending to ^ 3^ ->^ ^ 

form the outer wall of the attic, and to «l^ -pKzzrz', 

unite with the annulus tympanicus, d, i ; ^ ; : *^ _ , 

and at ? is seen the zygoma. In Fig. 5, 

at e, is the stylomastoid foramen, at / 

may be seen the stapes in the oval win- j. ' -^ 

dow, and at r/ is the situation of the ^ , c.v. ■ u^^ 

' -^ Inner surface of the right temporal bone 

jugular bulb, beneath the floor of the of infant, viewed directly from in front, a, 

drum-cavity. The latter and all its mner surface of the squama ; 6, zygoma ; c, 

^ . . , upper part of petrous pyramid ; d, Glaserian 

contents are the same size m the new- fissure ; e annuUis tympanicus ; /, bony Eu- 

born child as in the adult: but not so stachian tube, looking through the tube and 

, f.ii tvmpanic cavitv out of the annulus tympani- 

the rest of the temporal bone of the cus; ^,jugular'fossa; //.carotid canal, exit; 

infant. *- poms acustlcus internus ; k, subarcuate 

rrit T . • • 1 • 1 • J space ; I, lower posterior surface of petrous 

The annulus tympanicus, m which sits ^^^^^^^ . ^ ^pp^, p^gt^rior surface of pe- 
the membrana tympani, is not a com- trous pyramid. 
plete ring at birth, nor at any subse- 
quent time. It is deficient in its upper eighth, its circumference being 
completed for support of the membrana tympani at this point by the 




Fig. 8.1. 





Outer side of the annulus tympanicus, left 
ear. (Politzer.) a, tuberculum tympani anterlus ; 
p, tuberculum tympani posterlus. 

tympanic process of the squama 
(Fig. 5, Jc). On the concave side 
of the tympanic ring is a groove 
for the insertion of the membrana, 
the sulcus tymimnicus. 

On the outer surface of the tym- 
panic ring there are two enlargements, one on the front limb, the other 
on the posterior limb of the annulus. That on the anterior part of the 
ring (Fig. 8^, a) is called the anterior tympanic tubercle ; that on the 



Left tympanic ring of an infant turned for- 
ward uix)n its anterior limb and viewed from 
within. (Gruber.) h, anterior extremity of the 
ring, and just below it the spina tj'mpani major; 
sm, spina tympani anterior ; and between sm and 
h is the crista splnarum ; ct, the crista tympanica, 
ending below and in front in the spina tympani 
inferior, st, and above and behind in the spina 
tympani major ; between the crests lies the sulcus 
malleolarius ; r, posterior extremity of the ring, 
forming anteriorly the spina tympani posterior. 



8 



DISEASES OF THE EAR. 



posterior part (Fig. 8A, p) the posterior tympanic tubercle. From these 
two tubercles begins the ossification that forms the tympanic bone, the 
antero- inferior wall of the osseous auditory canal. Below the anterior 
tympanic tubercle is the so-called spina tympani inferior (Fig. 8B, st). 

On the inner surface of the anterior arm of the tympanic ring (Fig. 
8B, h) is a small spine, called the spina tympani major. This spine is con- 
cave on its posterior border and forms the anterior end of the incisura 
Eivini, lodging the head of the malleus. In front of and a little below 
the spina tympani major is another spine pointing outward and forward, 
called the spiiia tympani anterior. Connecting these two spines is the 
crista spinarum (Fig. 8B). Below the centre of the anterior border of 
the inner surface of the front arm of the tympanic ring there is a spine 
directed forward and inward, called the spina tympani inferior (Fig. 8jB, 
st). Between the spina major and the spina inferior is the crista tympanica 
(Fig. 8B, ct). Between the crista spinarum and the crista tympanica is a 
groove, called the sulcus maUeolarius (Fig. 8^, ct-st)^ which lodges part of 
the anterior ligament of the malleus, the processus gracilis of the malleus, 
the tympanic branch of the internal maxillary artery, gives passage to 
the chorda tympani nerve on its way to the tongue, and forms the anterior 
boundary of the Glaserian fissure. 




Base of infant's skull, from photograph, a, right zygoma ; h, right membrana ; c, annulus tympani- 
cus ; d, right mastoid portion ; /, foramen magnum ; e, left mastoid portion ; g, stylomastoid foramen ; 
h, jugular foramen ; i, umbo of the left membrana tympani ; k, annulus tympanicus, in front and 
above ; I, Glaserian fissure ; m, zygoma ; n, squama ; s, annulus tympanicus, in front and below ; r, left 
carotid canal ; p, q, basilar process of occipital bone ; o, right carotid canal. 

The anterior border of the tip of this surface is slightly prominent, 
and is called the spina tympani posterior (Fig. 85, v). It forms the 
posterior angle of the Eivinian incisure, and gives attachment to the 
posterior ligament of the malleus. 

At birth the plane of the annulus tympanicus and membrana tympani 



ANATOMY AND PHYSIOLOGY OF EXTERNAL AUDITORY CANAL. d 

conforms closely to the plane of the skull base (Fig. 9, ^, kj s), whereas in 
adult life it conforms more to the plane of the side of the skull. 

The gradual outward growth of the tj'mpanic ring forms the antero- 
superior, the anterior, and the antero- inferior walls of the bony auditory 
canal. To this development of the annulus tympanicus is also given the 
name of tympanic bone. 

The External Auditory Canal at Birth. — At birth the lower wall of the 
external auditory canal is almost in contact with the membrana tympani 
and the ui^per wall of the canal. This is due to the fact that at this 
time bone does not enter into the formation of the auditory canal, and 
hence its upper and lower fibro-cutaneous walls easily come together. 
The plane of the membrana corresponding at this time to that of the 
upper wall of the canal, the membrana is covered by the lower wall of 
the canal by this collapse. Therefore, in examining the ear of an infant, 
the auricle and the lower wall of the canal must be drawn downward in 
order to gain a view of the membrana tympani (Fig. 10). 

Fig. 10. 





Vertical section through the right external auditory canal of a human embryo of seven months, 
natural size. (G. Schwalbe.) a, section through the annulus tympanicus; ab, lamina tympanica 
fibrosa ; he, floor of the cartilaginous auditory canal ; ad, membrana tympani with the malleus in the 
drum-cavity ; d, e, part of roof of the canal near its meatus, formed by the temporal bone ; /, car- 
tilaginous auricle ; g, parotid gland. 

The neck of the malleus fits in between the two spines of the annulus 
tympanicus (Fig. 8^, v, h) in such a manner that the anterior, the spina 
tympani major, almost touches it. This relation of the parts is not seen, 
however, from without. The deficiency in the annulus tympanicus be- 
tween these two points is supplied by the tympanic process of the squama, 
the so-called ''scute" (Fig. 5, A-). The gradual outward growth of the 
annulus tympanicus, in front, below, and to some extent behind, together 
with the outward growth of the tympanic and mastoid surfaces of the 
squama above and behind, form at last the osseous external auditory canal 
(Fig. 11, t, c). The anterior wall of the auditory canal, developed en- 
tirely from the annulus tympanicus, is called the tympanic bone (Fig. 11, i). 
Together with the lower glenoid surface (Fig. 11,/) it forms the posterior 
wall of the joint of the inferior maxilla. Between the tympanic and the 



10 



DISEASES OF THE EAR. 



glenoid surface lies the Glaserian fissure (Fig. 11, h). It is thus shown 
that the front wall of the external auditory canal is the back wall of the 
maxillary joint, which explains the fact that in inflammation of the ex- 
ternal auditory canal motion of the jaw is painful. 

A view of the outer suyface of the temporal bone of the adult shows 
that the parietal surface of the squama (Fig. 11, ci) forms a sharper angle 
with the tympanic or horizontal portion (Fig. 11, c) than in the infant's 
bone. This is due to the outward or horizontal growth of the tympanic 




Fully developed left temporal bone, outer surface, a, squama ; h, groove for temporal artery ; c, 
external auditory meatus ; d, zygomatic process ; e, insertion of masseter muscle ; /, glenoid fossa ; 
g, articular ridge ; h, Glaserian fissure ; i, tympanic bone : anterior wall of external auditory canal ; k, 
inner end of petrous or pyramidal portion of temporal bone; I, insertion of styloglossus muscle; m, 
styloid process ; n, insertion of stylohyoideus muscle ; o, insertion of temporal muscle ; p, q, mastoid 
portion ; t, mastoid process ; r, insertion of sterno-cleido-mastoid muscle ; s. squamomastoid fissure ; u, 
mastoid incisure ; w, insertion of splenius capitis muscle ; r, insertion of trachelomastoid muscle. 



and mastoid portions of the squama with that of the annulus tympanicus, 
in the formation of the osseous auditory canal (Fig. 11, c, p, q, i). The 
groove for the temporal artery is seen running across the squama (Fig. 
11, 6), the external auditory meatus is now complete and ready for the 
attachment of the auricle, the zygoma is a strong process (Fig. 11, d) 
for the insertion of the masseter muscle (Fig. 11, e), and the glenoid fossa 
and the tympanic bone (Fig. 11, /, i) complete the posterior maxillary 
articular surface. 

The inner surface of the temporal bone of the adult is also important 
for otological study. It will be seen that the j)etrous pyramid of the 
bone divides the middle from the posterior cranial fossa, the posterior 



ANATOMY AND PHYSIOLOGY OF EXTERNAL AUDITORY CANAL. 11 

pyramidal surface being the anterior wall of the posterior fossa, and the 
anterior surface of the petrous pyramid, containing the tegmen tympani, 
forming the posterior wall of the middle cranial fossa. Over the tegmen 
tymj)ani and against the squama lies the temporal lobe of the brain. The 
meningeal artery courses over the inner surface of the squama (Fig. 12, Z>). 
On the posterior part of the petrous pyramid, at its upper boundary, 
may be seen the eminence made by the superior semicircular canal (Fig. 
12, Jc). Just below this runs the groove for the superior petrosal sinus 




Fully developed left temporal bone, inner surface, a, squama ; b, meningeal groove ; c, zygomatic 
process ; d, semi-canal of Vidian nerve ; e, hiatus of Fallopian canal ; /, canaliculus petrosus empties 
into this groove ; g, i)orus acusticus for auditory nerve ; h, carotid canal ; i, jugular notch ; r, o, petrous 
or pyramidal part of bone ; p, mastoid foramen for vein ; n, sigmoid groove for lateral sinus ; I, groove 
for superior petrosal sinus; k, eminence of superior semicircular canal; m. petrosquamous suture; 
s, aquseductus vestibuli. 

(Fig. 12, 7). This enters the lateral sinus (Fig. 12, n). The mastoid vein 
enters the same blood-channel at the mastoid foramen (Fig. 12, p). The 
jugular foramen is completed at the jugular notch (Fig. 12, ?), and the 
carotid canal has its exit at the point of the petrous bone (Fig. 12, h). 
The auditory nerve, with the facial nerve, enters the petrous bone at the 
porus acusticus internus (Fig. 12, g). Behind and below the porus 
acusticus is the entrance of the aquseductus vestibuli (Fig. 12, s), the con- 
veyer of endolymph to the membranous labyrinth. The perilymph es- 
capes from the labyrinth by the way of the aquseductus cochleae. Above 
and beyond the porus acusticus lie the semi- canal for the A^idian nerve and 
the hiatus of the Fallopian canal (Fig. 12, d, ■ e). Into this groove the 
canaliculus petrosus empties (Fig. 12, /). 



12 



DISEASES OF THE EAR. 



It should also be borne in mind tliat on the upx^er cerebral surface of 
the petrous portion of the temporal bone are the petrosal sinuses, closely 
connected with the cavernous sinus, and that into the latter, in turn, 
empties the ophthalmic vein, a relationshii? that explains the obstruction 
in the circulation of the veins of the face and eye occurring in otitic 
phlebitis and thrombosis in the cerebral sinuses. 

The Tinder Surface of the Temporal Bone. — Under the floor of the drum- 
cavity lies the jugular bulb (Fig. 13) ; the anterior wall of the drum- 

FiG. 13. 




Under surface of the left temporal bone. (Gray. ) a, canals for Eustachian tube and tensor tym- 
pani muscle ; 6, tensor tympani ; c, levator palati ; d, rough quadrilateral surface ; e, opening of carotid 
canal;/, canal for Jacobson's nerve ; g, aquseductus cochleae; h, canal for Arnold's nerve; i, jugular 
fossa ; Tc, vaginal process ; I, styloid process ; m, stylomastoid foramen ; n, jugular surface ; o, auricular 
fissure ; p, stylopharyngeus. 



cavity is part of the carotid canal (Fig. 13) ; the roof of the drum-cavity 
is a thin septum of bone forming part of the floor of the middle cranial 
fossa 5 and the mastoid cells are separated by a thin partition of bone 
from the sigmoid groove, or fossa, in which runs the lateral sinus of the 
dura mater, and beyond which lies the posterior cranial fossa. Inspec- 
tion of the base of the temporal bone (Fig. 13) shows that the medial 



ANATOMY AND PHYSIOLOGY OF EXTERNAL AUDITORY CANAL. 13 

wall of the mastoid process forms part of the digastric groove or fossa ; 
the canal for Arnold's nerve lies in the jugular fossa; the canal for 
Jacobson's nerve lies between the jugular and the carotid; and the 
bony portion for the Eustachian tube and the semi -canal for the tensor 
tympani muscle have their inner wall in common with the outer wall of 
the carotid canal, on the inner end of the petrous portion or pyramid of 
the temporal bone. It must also be borne in mind that the entire in- 
ternal ear or labyrinth lies in the petrous part of this important bone 
(Fig. 12, k). 

The Auditory Canal. — The completely developed external auditory 
canal extends from the bottom of the concha to the drum-head, and con- 



FiG. 14. 




Vertical section of the external auditory canal, membrana tympani, and tympanic cavity, viewed 
from in front. (Politzer.) a, upper osseous ■wall of the canal ; n, lower osseous wall of the same ; b, 
tegmen tympani ; c, osseous floor of the tympanic cavity ; d, tympanic cavity ; e, membrana tympani ; 
/, head of the malleus ; g, lower end of the handle of the malleus ; o, short process of the malleus ; h, 
body of the incus ; i, stapes in the oval window ; k, Fallopian canal ; I, jugular fossa ; ??i, glandular 
orifices in the skin of the cartilaginous canal. 



sists of a cartilaginous and bony portion, the former being about one- 
third, and the latter about two-thirds, of the passage-way. The length 
of this canal is about one inch and a quarter, and its average width about 
a quarter of an inch. The canal gradually narrows to the middle of the 
bony portion (Fig. 14, a-n), where it widens again gradually to the mem- 
brana tympani. The external auditory canal is lined with skin, a con- 
tinuation inward of that of the auricle, and 7iot with mucous inembrane. 
The skin of the auditory canal is extended over the outer surface of the 
membrana tympani, forming the extremely thin and delicate dermoid, or 
outer layer (Fig. 14). In the bony portion of the auditory canal the skin 
is thin and closely adherent to the bony walls. It forms a very sensitive, 
silvery-white cutaneo-periosteum, and by reason of its sensitiveness acts 



14 



DISEASES OF THE EAR. 



Fig. 15. 



as a protection to the drum- membrane by warding off manipulation of 
tlie canal walls near the membrana. In the anterior wall of the carti- 
laginous auditory canal there are deficiencies called the incisurce Santorini 
(Fig. 15; c, c), and there is also a cleft in the upper wall of the cartilagi- 
nous part of the auditory canal. The general course of the adult's external 
auditory canal may be said to be sigmoid or spiral, turning inward and 
downward. Hence, to inspect the membrana tympani through the audi- 
tory canal, the auricle must be drawn slightly upward and backward to 
straighten the canal and permit the entrance and refl^ection of light. In 
some individuals the auditory canal is so straight that the membrana 
tympani can be seen at the bottom of the canal without traction on the 
auricle or dilatation of the meatus by an ear-funnel. In the negro race 
the auditory canal is usually very wide and straight. 

Upon the entire free surface of the cutis of the auditory canal are 
found epidermis and delicate, short hairs, together with the sebaceous 
glands usually found therewith. Throughout the canal, but especially in 

the cartilaginous portion, are found 
numerous modified sudoriferous glands, 
constituting the ceruminous glands of 
the meatus. 

Ceruminous Glands. — These glands 
begin about two millimetres from the 
opening of the auditory canal and ex- 
tend to within two or three millimetres 
of the drum-head. They are most 
numerous at the junction of the carti- 
laginous with the bony canal, where 
they average as many as ten to the 
square millimetre. According to Bu- 
chanan, there are from one to two 
thousand wax glands in each auditory 
canal. The skin in the cartilaginous 
part of the auditory canal is one and 
one-half millimetres thick. 

Vessels and Nerves. — The arteries 
supplying the auditory canal are 
branches from the posterior auricular, internal maxillary, and temporal 
branches of the external carotid artery. The nerves are chiefly derived 
from the temporo-auricular branch of the inferior maxillary nerve. There 
is also an auricular hranch of the pneumogastric nerve. The plexus of the 
sympathetic nerve, distributed to the external carotid artery, communi- 
cates with the otic and submaxillary ganglia by means of the plexus 
distributed to the facial and internal maxillary arteries. 

Relation of the Fallopian Canal to the External Auditory Canal. — Accord- 
ing to Gelle (Annales des Maladies de V Oreille, etc., January, 1894), the 




The auricle and tlie cartilaginous part 
of the external auditory canal, left side. 
(Politzer. ) a, cartilaginous meatus ; 6, inner 
pointed end which unites with the osseous 
part of the auditory canal ; c, c, fissures of 
Santorini. 



ANATOMY AND PHYSIOLOGY OF EXTERNAL AUDITORY CANAL. 15 

Fallopian canal, on its way from the drnm-cavity to the stylomastoid 
foramen, crosses the posterior edge of the ring of the membrana tympani 
at a point where a line drawn horizontally through the nmho of the mem- 
brana reaches the posterior wall of the osseous auditory canal. At this 
point the Fallopian canal is only from two to three millimetres from the 
surface of the posterior wall of the auditory canal. The extra-tympanic 
portion of the Fallopian canal continues to be superficial in the posterior 
wall of the auditory canal for a distance of five millimetres, being in this 
tract from three to four millimetres from the surface. Then the canal 
passes deeper inward and downward into the bone to reach the stylomas- 
toid foramen. 

Escape of Cerumen from the Ear. — The ear-wax is formed in the wide 
end of a detruncated cone, — i.e., near the outer end of the auditory canal. 
Therefore, as the ear-wax forms and collects it presses upon the walls of 
the auditory canal, which being widest and freest towards its mouth on 
the outer side of the gradually growing mass of cerumen, the latter meets 
with the least obstruction just in the direction of its only way of escape. 
Hence the wax ball will be acted upon very much as if it remained a 
constant quantity continually pressed upon from behind and pushed out- 
ward by a gradually narrowing auditory canal. 

Another force aiding in the outward movement of a ball of ear-wax, if 
let alone, is the fact that there is a natural outward growth of the skin of 
the auditory canal from the membrana tympani towards the external 
meatus. This can be seen by watching a small scratch on the dermoid 
sui'face of the membrana. Such a mark will be observed to move gradu- 
ally away from the malleus, across the membrana, and finally out onto 
the wall of the auditory canal, just as a spot on the finger-nail moves 
from the matrix towards the finger-end. 



CHAPTEE III. 
THE ANATOMY AND PHYSIOLOGY OF THE MEMBEANA TYMPANI. 

Dermoid Layer. — The membrana tympani, or drum-head, is situated 
at the fundus of the external auditory canal, and is composed of three 
layers, — viz., the external or dermoid layer ; the middle or fibrous layer, 
also called the membrana propria ; and the internal or mucous layer. 
The dermoid layer of the membrana tympani is a continuation of the 
delicate cutis of the external auditory canal. On this layer there are, 
however, no hairs or follicles such as are found elsewhere in the cutis of 
the auditory canal. In other respects it is true skin, but very thin and 
transparent. 

The Outer Surface of the Membrana Tympani. — The dermoid layer is the 
only one of the three layers of the drum-head which can be inspected 
directly from without. When the auditory canal is illui^inated and a 
normal membrana tympani looked at from without, there are several 
prominent features in it attracting immediate attention, — viz., its almost 
circular shape and peculiar polish and color ; its vertical and horizontal 
Inclinations ; the handle or manubrium of the malleus ; the short process 
of the malleus ; the folds of the membrana tympani ; the flaccid i^ortion 
of the drum-head above these folds, the so-called membrana. flaccida, or 
Shrapnell's membrane ; and the bright triangular reflection of light in 
the antero-inferior quadrant of the membrana, called the ''triangle or 
pyramid of light." In most normal membranse there may be seen also in 
the superior-posterior quadrant the long process of the incus showing 
through from the drum- cavity. The examiner of the normal membrana 
will also perceive that its general surface is concavo-convex, or of a 
broad and shallow funnel shape, with its centre at the umbo at the lower 
end of the malleus handle. 

Segment of Eivinus. — The line of attachment of the membrana tympani 
shows a slight, ill-defined depression where it passes above the short pro- 
cess of the malleus. This segment of the upper periphery of the tym- 
panic ring is called the segment of Eivinus, since it includes the foramen 
described by him as representing in some cases the trace of the first 
visceral cleft, but which has no existence in the vast majority of full- 
grown ears. 

Shape of the Membrana Tympani. — For purposes of clinical convenience 
in description, the periphery of the membrana tympani is called circular. 
Strictly it is an ellipse, the long diameter of which, amounting to from nine 
to ten millimetres, runs from above and in front, downward and backward, 
and the diameter of greatest width of which runs from below and in 
16 



ANATOMY AND PHYSIOLOGY OF THE MEMBRANA TYMPANI. 17 

front, upward and backward. The proi^ortion between these diameters 
is as 4.3 is to 4. (Hyrtl and von Troeltsch.) The longer diameter is 
called the vertical diameter, the diameter of greatest width is called the 
horizontal diameter, and the membrana is spoken of as circular. The 
latter is, therefore, divided into quadrants which greatly aid in locating 
points to be described. 

Color of the Membrana Tympani. The color of a normal membrana 
varies in individuals just as the color of normal teeth varies from bluish 

Fig. 10. 



Base and squama of the left i)etroiis bone sho^^'ing the inclination of the membrana tympani in 
the adult, natural size, from photojj:rai)h. a, b, section through the zygoma: c, upper anterior glenoid 
surface ; d, short process of malleus : membrana flaccida above it ; e, cut edge of anterior wall of the 
osseous auditory canal partly removed to show the membrana in position ; /, membrana tympani ; 
g, Glaserian fissure ; h, anterior wall of U\e osseous auditory canal ; i, foramen ovale ; k, foramen rotun- 
dum ; X, foramen lacerum ; I. articular condyle, and m, basilar process, of the occipital bone ; n, an- 
terior condyloid foramen ; o, jugular foramen ; p, carotid foramen, oblique view ; q, occipital surface ; 
r, umbo of the membrana ; .s-, digastric groove ; t, outer mastoid surface ; u, upper posterior wall of 
auditory canal ; v, squama ; u\ parietal surface. 

to yellowish white. Just so a normal membrana tympani may be 
bluish or yellowish gray. It is generally spoken of as " pearl -gray, " but 
whatever its color may be, it is always modified by the i^hysical con- 
ditions brought about by its being a nearly transparent membrane 
stretched over a darkened cavity. Its color must always be modified by 
the color and condition of the contents of the drum- cavity. That part 
of the membrana behind the lower end of the malleus handle is rendered 



18 DISEASES OF THE EAR. 

yellowish gray by the light reflected from the promontory of the cochlea 
on the inner tympanic wall. 

Lustre of the Membrana Tympani. — The membrana tympani owes its 
peculiar lustre to the delicate and shining epithelium of the dermoid 
layer. The slightest maceration or exfoliation of this epithelium de- 
prives the membrana of its beautiful lustre. The dermis of the drum- 
membrane is thickest in young children. 

Inclinations of the Memhrana Tympani. — The normal membrana tym- 
pani in the adult is inclined outward at an angle of forty-five degrees in 
its vertical plane. In a horizontal plane the membrana is inclined at its 
posterior periphery on the right side ten degrees farther to the right than 
the anterior boundary, and on the left side, in the same sense, ten degrees 
farther to the left. If the planes of both membranse be extended downward 
until they intersect each other, the angle thus formed will equal from one 
hundred and thirty to one hundred and thirty-five degrees. If a perpen- 
dicular be drawn from the upper pole of the membrana to the inferior 
wall of the auditory canal, it will strike the latter about six millimetres 
from the inferior pole of the drum-head, A similar result will be obtained 
by drawing a perpendicular from the middle of the posterior periphery 
of the membrana to the anterior wall of the auditory canal. From this 
it is seen that the posterior segment of the membrana tympani is nearer 
the mouth of the external auditory canal than is the anterior segment. 
The plane of the adult membrana tympani corresponds more nearly 
to the plane of the side of the skull (Fig. 16, /), while the plane of 
the membrana in the infant and young child corresponds very nearly to 
that of the base of the skull (Fig. 9, s and i ; 1) and c). 

Sometimes the segment of Eivinus is filled in with osseous tissue, and 
in consequence the superior wall of the auditory canal dips downward to 
join the membrana tympani on a line with its folds. In such cases there 
is very little or no membrana flaccida. Such conditions I have observed 
most frequently in the feeble-minded or in any one with defective cranial 
development. 

Manubrium of the Malleus. — Running from the superior pole of the 
membrana, downward and slightly backward to the centre of the drum- 
head, is seen the ridge formed by the manubrium, or handle of the mal- 
leus (Fig. 17, h-f). This slightly elevated ridge, entirely opaque and 
decidedly whiter than the surrounding drum-head, divides the membrana 
tympani into its two segments, the anterior and the posterior. At the 
upper end of this ridge, in the line of the folds of the membrana and 
beneath the membrana flaccida (Fig. 17, a), is the short process of the 
malleus, projecting sharply outward somewhat above the general surface 
of the handle of the hammer (Fig. 17, h). Its general appearance is not 
unlike a pimple with pale-yellow contents. 

The lower end or tip of the ridge, which curves slightly forward, is 
flatter, broader, and yellower than the rest of the outer covering of the 



ANATOMY AND PHYSIOLOGY OF THE MEMBRANA TYMPANI. 



19 



manubrium. This is due to the fact that the bone proper is spade- shaped 
at this point, and also because the radial fibres of the membrana propria 
centre at this lower part of the bone. The lower end of the manubrium 
draws the membrana tympani inward very markedly, and forms the 
pale-yellow depressed spot in the centre called the umbo. 

Fig. 17. 




Fig. 18. 



Left membrana tympani in position ; anterior wall of the osseous auditory canal cut away ; adult 
bone, from photograph, a, membrana llaccida, or Shrapnell's membrane ; b, short process of malleus ; 
c, anterior Avail of internal auditory canal, for auditory nerve ; g, cochlea ; /, membrana tympani ; 
e, mastoid process ; d, upper back wall of osseous external auditory canal. 

The convex shape of the drum-head from the tip of the manubrium 
outward towards the periphery is due to the comparatively large number 
of circular fibres at a point between the 
umbo and periphery, which constrict, as 
it were, the radial fibres, so as to form 
a kind of funnel. 

Pressure or traction applied to 
centre of a membrane stretched over 
ring tends to draw the former into 
cone. But if a smaller concentric ring 
be placed so as to resist the indrawing 
force at the centre, the whole membrane 
is drawn into a concavo-convex shape. 

Folds of the Membrana Tympani. — From 
the short process of the malleus two deli- 
cate ridges may be seen, one running for- 
ward, the other backward, to the periph- 
ery of the membrane. They are the so- 
called folds of the membrana tympani 



the 
a 
a 




Outer surface of the membrana tym- 
pani ; enlarged four diameters. (Politzer. ) 
V, h, annulus tympanicus ; s, s', folds of 
the membrana tympani ; vis, membrana 
flaccida, or Shrapneirs membrane. 



(Fig. 18, s, s'). The sharply defined crests 

of these ridges have been called by some 

Frussak^s bands. Above these folds and bands is the so-called membrane 

of ShrapneU, or membrana flaccida. This flaccid membrane consists only of 

dermoid and mucous layers, the fibrous layer being wanting at this point. 

The feeble resistance of this part of the membrana renders it easy of per- 



20 



DISEASES OF THE EAR. 




Left. 



Right. 



Fig. 20. 



foration, which may have given rise to the now exploded idea that there 
was a normal opening at this pointy the so-called foramen of Eivinus. 

Pyramid of Light— The pyramid of light is a name applied to the 
beautiful triangular reflection of light emanating from the antero-inferior 
quadrant of the normal membrana tympani. The apex of this triangular 
reflection touches the tip of the manubrium of the malleus, and its base 
lies on the periphery of the membrana tympani. It 
forms, with the handle of the malleus, an obtuse angle 
anteriorly, which becomes greater as the inclination 
of the membrana tympani to the auditory canal 
diminishes. Its average height is from one and one- 
half to two millimetres, and its average width at the 
base is from one and one-half to two millimetres. This reflection, which 
has been called an isosceles triangle from its general appearance, is, 
strictly considered, pyramidal in shape, and hence the name applied to 
it by most writers of the present day (Fig. 19). 

Geometric Divisions of the Membrana Tympani. — For clinical convenience 
the membrana tympani may be divided into quadrants and the region 

of the membrana flaccida (Fig. 20). 

Annulus Tendinosus. — The so-called annulus 
tendinosus, ^ or tendinous ring of Arnold, is a mass 
of fibrous tissue arranged around the periphery 
of the membrana tympani, effecting the union 
between the latter and the inner edge of the 
external auditory canal. 

The annulus tendinosus is not found, however, 
at that part of the periphery of the membrana 
tympani corresponding to the Eivinian segment, 
nor is it always visible from without, even when 
present in its normal position, around the periph- 
ery close to the annulus tympanicus. 

The fibres of the membrana propria, described 
farther on, are not inserted directly into the bone 
of the manubrium, but into a cartilaginous groove which receives the 
manubrium and short process. 

Inner Surface of the Cartilaginous Groove. — The inner surface of this 
cartilaginous groove, which is in contact with the malleus, is lined by a 
very delicate layer of connective tissue, between which and the malleus 
there is found a small amount of fluid resembling synovia. As this con- 
dition of discontinuity between the malleus and the inner surface of the 
cartilaginous groove is considered normal, it is fair to presume that, such 
being the case, the malleus can make a certain amount of motion in this 
groove, and that therefore there is here a kind of joint. 




Quadrants of the membrana 
tympani and the membrana flac- 
cida. (Siebenmann.) 



The annulus cartilagineus of the older writers. 



ANATOMY AND PHYSIOLOGY OF THE MEMBKANA TYMPANI. 



21 



I have seen cases that appeared to have two short processes projecting 
from the upper end of the manubrium. Such an appearance is explained 
by Gruber as the result of a dislocation or slipping upward of the entire 
malleus out of this cartilaginous groove 5 the upper of the ^'two short 
processes" in such a case is the true bony short process, whereas the lower 
one is the aforesaid cartilaginous cap, moulded over the short process, and 
held in the original position of the true short process by the membrana 
tympani. This condition is due to a subluxation of the cartilage from the 
short process. 

TJie Memhrana Propria^ the Fibrous or Middle Layer of the 2Iembrana 
Tympani. — The memhrana propria can be subdivided into two distinct and 
delicate layers, — viz., an outer, composed entirely of radiate fibres inti- 
mately connected with the dermoid 

layer of the drum-head ; and an in- Fig. 21. 

nevj composed entirely of circular n 

fibres in close relation with the mu- 
cous membrane composing the inter- 
nal layer of the membrana tympani. 
These component layers of the mem- 
brana propria are named, briefly, the 
radial and the circular layer. The 
fibres composing the former arise 
from the annulus tendinosus and the 
upper wall of the auditorj^ canal, and 
are inserted into the manubrium of 
the malleus, centring for the most 
part at its spade-like tip. The fibres 
composing the circular layer arise 
partly from the annulus tendinosus, 
but the majority of them arise from 
the substance of the membrana tym- 
pani itself (von Troeltsch). Some of 
them are inserted into the malleus. 

Constituent Elements of the 
Memhrana Propria. — Toynbee, von 
Troeltsch, Gerlach, and Gruber have 
added to the knowledge of the na- 
ture and dimensions of the constitu- 
ent elements of the membrana propria. 

It consists chiefly of connective tissue of that variety half-way between 
the ordinary fibrillated and the homogeneous connective tissue of Eeich 
ert, as shown by Gerlach. 

The fibres are 0.004'" broad and 0.002"' thick, and on account of their 
ribbon-like shape they were once supposed to be uustriated muscle fibres, 
which they are not. On these fibres certain peculiar spindle-shaped cor- 




Inner surface of the ri.^ht membrana tjTn- 
pani, -vvith the malleus and incus attached to 
each other, enlarged three and one-half times. 
(Politzer.) n, niche in the outer wall of the 
tympanic cavity, in the squama ; h, head of the 
malleus ; a, short process of the incus ; pi, fold 
of the posterior pouch of the membrana tjTn- 
pani ; ct, chorda tympani nerve. The fold of 
the anterior pouch of the membrana lies in front 
of the neck of the malleus, concealing the upper 
anterior attachment of the membrane and car- 
rying the chorda tympani nerve to the anterior 
osseous wall and to the Glaserian fissure. 



22 



DISEASES OF THE EAR. 



puscles are found. The latter were supposed to be peculiar to the mem- 
brana tympani, and have been called '' corpuscles of the membrana tym- 
panij" or the '^corpuscles of von Troeltsch/' after the observer who first 
drew attention to their existence. They, are, however, connective-tissue 
corpuscles of Yirchow. They are about 0.002'" long and 0.005"' wide 
at their broadest part, with from two to three processes. According to 
Gruber, these bodies are found in two varieties in the membrana tym- 
pani, — viz., the spindle-shaped and the stellate variety. 

The Internal or Mueous Layer of the Membrana Tympani. — The internal 
layer of the membrana tympani is composed of mucous membrane, a 



Fig. 22. 




Pouches of the membrana tjonpani in their relation to the membrana flaccida. (Siebenmann.) 
1, attic and aditus ; 2, upper pouch of the membrana ; 3, posterior pouch ; 4, membrana tympani ; 
5, malleo-incudal space ; 6, anterior pouch of the membrana ; 7, Eustachian tube. 



reflection of that lining the tympanic cavity. It is thickest at that point 
where it leaves the cavity of the middle ear and passes over the periph- 
ery of the drum-head. It grows gradually thinner as it approaches the 
centre of the membrana tympani, where it is extremely delicate. 

On the inner surface of this layer various observers, among whom may 
be named Politzer, Gerlach, and Kessel, have found villi or papillae. 

Fold of Mucous Membrane for the Chorda Tympani. — The mucous mem- 
brane of the tympanic cavity covers the entire inner surface of the mem- 
brana tympani. I^ear the upper boundary of the latter it is reflected 
over the chorda tympani and back again to the drum-head. 

By this means a duplicature or fold of mucous membrane is formed, 
the opening of which is turned towards the surface of the membrana 



ANATOMY AND PHYSIOLOGY OF THE MEMBRANA TYMPANI. 23 

tympani, and in the cul-de-sac or inner edge of which the chorda tympani 
is found. 

Pouches of the Memhrana Tympani. — The aforesaid fold is adherent to 
the inner surface of the neck of the hammer, and being thus divided 
into an anterior and posterior portion, contributes to make the inner 
boundaries or sides of the two pouches of the membrana tympani 
described by von Troeltsch. Further explanation of the pouches will 
be given under the consideration of the contents of the tympanic cavity. 

Vascular Supply of the Membrana Tympani. — The membrana tympani 
obtains its blood-supply from the tym^^anic branch of the inferior maxil- 
lary artery, and also by means of a short, direct branch from the internal 
carotid in the carotid canal. By the latter channel, the membrana may 
become quickly engorged. 



CHAPTEE lY. 

THE ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY. 



EMBRYOLOGY OF THE TYMPANIC CAYITY. 

The first trace of the middle-ear cavities is formed by the first inner 
branchial furrow or pharyngeal pouch, a dilatation of the lateral pharyn- 
geal tract. In the first month of embryonal life this broad, pit-like 
pouch, still open towards the pharynx, as far as can be decided from its 
relation to the internal carotid, corresponds to the middle third of the 
drum- cavity. By the middle of the sixth week of embryonal life it forms 
a narrow cleft running in the frontal plane. The floor of the pouch, run- 
ning steeply towards the pharynx, now reaches as far as the carotid, so 
that the anterior or tubal portion of the drum- cavity is formed and may 
be regarded as in some degree fully marked off. The point of the 
pouch corresponding to the posterior end of the foetal tympanic cavity 
lies between the handle of the hammer and the long process of the anvil. 
This is not directed exactly outward, but is curved somewhat backward. 
The two foetal drum-cavities at this time appear like wing-shaped, lateral 
appendages of the pharynx. (Siebenmann. ) 

At this time no parietal piece exists corresponding to the Eustachian 
tube. However, the increase in length of the tubo-tympanal space keeps 

equal pace with the rapid increase 
Fig. 23. in thickness in front of the laj^er 

of soft tissue surrounding the 
pharynx. In this way, as the audi- 
tory canal is inserted between the 
concha and membrana tympani, 
the Eustachian tube inserts itself 
after the sixth week between the 
pharynx and middle ear. (Sie- 
benmann. ) 

The tympanum and the Eusta- 
chian tube, derivatives of the en- 
toderm, are to be regarded as 
difl'erentiations of the primitive 
pharyngeal cavity. The dorsal 
part of the closing membrane of 
this cleft persists as the tympanic 
membrane. The outer layer of the membrana originates from the ecto- 
derm, the inner layer from the entoderm, and the middle fibrous layer 
from the mesoderm. 

24 




Cast of the middle ear of new-born child, right 
side. (Siebenmann.) 1, Eustachian tube; 2, attic ; 
3, antrum ; A, malleus ; 5, incus. 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY. 



25 



Auditory Ossicles. — Tlie foundation of the stapes in the human embryo 
appears at the end of the fourth week as an irregular layer of blastema 
rich in cells. This lies in the dorsal wall of the first pharyngeal pouch, 
and externally is in continuous connection with the blastema correspond- 
ing at that point to the richly cellular, blending tract of the first and 
second branchial arches. 

The malleus and incus are not, even in the fifth week, indicated by 
any special grouping of cells. At the beginning of the sixth week, how- 
ever, the anterior cartilaginous structures of the first and second branchial 
arches differentiate, and simultaneously with the appearance of Meckel's 
and Eeichert's cartilaginous rods appear also indications of the malleus 
and the incus. Ossification of a piece of the proximal end of Meckel's 
cartilage, the so-called articidare, produces the maUeus. Ossification of 
the piece of cartilage remaining from the paJato-quadratum, representing 
the proximal end of the original bar of cartilage in the mandibular arch, 
forms the incus. 

ANATOMY. 

Under the term Middle Ear are included the tympanic cavity and its 
two very important adjuncts, — the Eustachian tube in front, and the 
mastoid portion of the temporal bone, and its cells, behind (Fig. 24). 




Cast of middle ear of a child of nine months, outer surface. (Siebenmann.) 1, Eustachian tube; 

2, large pneumatic cell of the inner and upper wall of the osseous part of the Eustachian tube ; 

3, attic ; 4, antrum, encroached upon by mastoid cells. 

Ossicles of Hearing. — In the tympanic cavity of all mammals are three 
small bones, — the malleus, or hammer ; the incus, or anvil ; and the stapes, 
or stirrup. 

Anatomists of a later day have shown that the once so-called os orbicu- 
lar e, or OS Sylvii, does not exist as a separate ossicle. That which once 
received this name is the xjrocessus lenticularis of the long limb of the 
incus, which fits into a corresponding depression in the head of the 
stapes. 

The Malleus. — The malleus, or mallet, is divided into head, neck, and 
handle (Fig. 25). At the junction of the handle with the neck are two 
important processes, — viz., the short process on the outer surface, which, 
when in its normal situation, pushes the membrana tympani ahead of it. 



26 



DISEASES OF THE EAR. 



and points towards the auditory canal, and the process of Bau or Folius, 
which passes anteriorly into the Glaserian fissure. In the foetus and 
new-born child this process is about three and one-half lines long, and 
can then be removed whole in connection with the malleus. After birth 

Fig. 25. 





Right malleus : A, from in front ; B, from behind ; magnified four diameters. (Henle.) a, head ; 
b, short process ; c, long process ; d, manubrium ; e, articular surface ; /, neck. 

it unites with the under wall of the Glaserian fissure, and when the 
malleus is removed, only a short piece of the former long process is 
found attached to it. This remnant was all that was known of the long 
bony process to the older anatomists, and it has been called the pro- 
cessus Folianus, after Folius/ who, in describing this process, alluded 
only to the remnant. 

The head and neck of the malleus project into the tympanic cavity, and 
are entirely free from the membraua tympani (Fig. 23, 4). The rounded, 
smooth surface of the head is directed anteriorly, while the surface which 
articulates with the incus is directed backward. The long diameter of 
its articular surface runs vertically ; the short diameter, horizontally. 

In the direction of the former, the articulating surface has been said 
to resemble a saddle, for the surface is divided a little below the middle 
by a horizontal ridge, and depressed on each side of it. This articulating 
surface is also concave in the direction of its short diameter, — i.e., from 
without inward. 

The necJc of the malleus lies between the head and the manubrium. 
It makes, with the former, an angle of about one hundred and thirty-five 
degrees when viewed from in front. It has three surfaces, — a broad inner 
one directed towards the tympanic cavity, bounded in front by the pro- 
cessus Ravii, or long process, and behind by the long, low, bony elevation 
for the insertion of the tendon of the tensor tympani ; an anterior surface^ 
lying above the ridge joining the processus brevis and the processus 
longus, and extending to the angle made by the head of the malleus with 
the neck, and separated from the posterior surface by a sigmoid-shaped 



^ Caelius Folius, Venice, 1645. Nova auris interna deliiieatio. 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY. 2i 

ridge for the insertion of the ligamentum mallei externum of Helmholtz ; 
and the posterior surface, which lies between the aforesaid sigmoid ridge 
in front, the edge of the articulating surface of the malleus above, the 
low, long process behind, and a line drawn from the insertion of the 
tensor tympani to the short process below. Of all the surfaces of the 
neck, the posterior glides most gradually into the manubrium. The 
handle or the manubrium of the malleus, that part of the bone inserted 
into the membrana tympani, has also three surfaces, which may be con- 
sidered prolongations downward of those of the neck. Since they all 
gradually approach one another and are united in the lower pointed end 
of the manubrium, the latter may be said to resemble a three-sided 
bayonet, one ridge of which passes from the short process directly down- 
ward to the tip, and is consequently turned towards the external auditory 
canal. The point or lower end of the handle of the malleus is flattened 
into a small disk, one surface of which is turned towards the auditory 
canal. This spot is plainly visible as the pale, round centre of the umbo. 

The long axis of the handle of the hammer is convex posteriorly and 
Inward, so that when viewed from without the manubrium appears con- 
cave on its anterior and outer surfaces. This is especially marked at 
the lower third on the anterior surface, so that the manubrium normally 
appears curved decidedly forward near its lower end, of course in the 
plane of the membrana tj^mpani. Along the ridge of the manubrium, 
directed towards the external auditory canal, several little node-like 
prominences are not uncommonly seen. These are not pathological, but 
purely phj^siological. Their origin is obscure. 

Dimensions of the Malleus. — The malleus is nearly nine millimetres 
long ; its manubrium is between four and five millimetres long, and its 
head is two and one-half millimetres thick. The latter is the greatest 
diameter of any part of the bone, which gradually tapers to the point of 
the handle. 

The long diameter of the articulating surface of the malleus is about 
three millimetres ; the short diameter is between one and one-half and 
two millimetres. 

Fixation of the Malleus. — The malleus is held in position by four liga- 
ments, — viz., the ligamentum mallei anterius, ligamentum mallei superius, 
ligamentum mallei externum, and ligamentum mallei posterius. The 
ligamentum mallei anterius is a broad band of fibres which holds the pro- 
cessus Folianus against the spina tympanica major. This ligament may 
be said to arise from the spina tympanica major, and to be inserted along 
the neck of the malleus all the way from the processus Folianus to the 
head of the malleus. A part of it also runs from the processus Folianus 
to the shoit process of the malleus below and the membrana tympani 
above, aiding thereby the division between the anterior and posterior 
pockets of the membrana tympani ; another fold of the same ligament 
runs from the i^rocessus Folianus downward with a free margin as far as 



28 DISEASES OF THE EAR. 

the line corresponding with the insertion of the tensor tympani muscle. 
This aids in making the limiting wall between the anterior pocket of the 
drum-head and the tympanic cavity (Fig. 26). 

The round ligamentum mallei superius descends obliquely downward and 
outward from the tegmen tympani to the head of the hammer. Its func- 
tion is to prevent the malleus from being forced outward. 

The ligamentum mallei externum is a very important collection of satin- 
like, tendinous fibres, which radiate from the sigmoid crest on the front 
of the neck of the hammer and are inserted into the sharp edge of the 
segment of Eivinus on the temporal bone. It prevents the hammer 
from being forced inward, and, being inserted above the axis of rotation 
of the hammer, it prevents the manubrium, which is below the axis 
of rotation, from moving too far outward towards the auditory canal 
(Fig. 26). 

The ligamentum mallei posticum is really the posterior edge of the liga- 
ment just described as the external ligament of the hammer. As the line 
followed by this bundle of fibres passes through the spina tympanica ma- 
jor, and as it represents pretty closely the axis of rotation of the hammer, 

Fig. 26. 



Ligamentous support of the ossicles viewed from above. (Helmholtz.) l-h, attachment of the liga- 
mentum mallei externum ; k, head of hammer ; i, body of incus ; /, point of its short process ; a, en- 
trance to the Eustachian tube from the tympanum ; c, stapes ; d, tendon of the stapedius muscle ; b, ten- 
don of the tensor tympani, leaving the cochlear process ; g-g, chorda tympani, marking the free edge of 
the fold of mucous membrane, bounding the jxjuches ; n, upper tendinous fibres of the ligamentum 
mallei anterius, originating above the spina tympanica major, m; j, malleo-incudal joint. 

Helmholtz has suggested that it should be considered a separate ligament, 
and has given to it the name it bears. As this ligament and the liga- 
mentum anterius are in a mechanical sense one ligament, although the 
hammer intervenes between them, Helmholtz has called the two sets of 
fibres the axis-ligament of the malleus (Fig. 26). 

Axis- Ligament of the Malleus. — The plane of this ligament is not 
quite horizontal, being a little higher in front than behind. 

In all its motions as a lever the hammer swings about this axis-liga- 
ment as a fixed point. All above the short process of the malleus is 
above, and all below the short process is below, the axis- ligament. 

The ligamentum mallei anterius of Arnold was once described as a mus- 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY. 29 

cle, the laxator tympani major.^ It is not, however, anything more than 
a ligament which originates from the spina angular is of the sphenoid, 
passes through the petro-tympanic fissure, ^ and is inserted into the mal- 
leus. 

Under the name Ugamentum mallei post imun seu manubrii, the ligamentum 
mallei externum of Arnold, Lincke describes a ligament which passes 
from the upper edge of the end of the external auditory canal to the 
short process of the malleus, and occupies the position of a supposed 
muscle, once called the M. laxator tymjpani minor, or M. mallei eoderior seu 
Casserii. It is now universally acknowledged that muscular fibres do not 
exist here. ^ 

IncuSj or Anvil. — The middle one of the three auditory ossicles is the 
incus, or anvil. The name is derived from the shape of its upper half. 
This small bone is divided into a body and two processes, — viz., a short 
and a long one. The former of these two processes is also called the 
horizontal process. It is held to the posterior and to the upper wall of 
the tympanic cavity by ligaments.* This is an important point in the 
mechanism of the auditory ossicles.^ 
The longer process is also called the ^ '^^^' 2' 

descending ramus of the incus (Fig. 
27, c). It curves gradually outward, 
— i.e., towards the external ear, away 
from the vertical plane of the body of 
the incus, assuming a slight sigmoid 
shape ; at its tip it curves rather 
sharply inward, to unite with the head 
of the stapes by means of the processus 
lenticularis (Fig. 27, d). 

rrii , i- x- j-T_ • • ^ Right incus ; magnified four diameters. 

The narrowest part of the incus is at ^3,^^, ^ ^ i^^,, ^^^^^^^ . ^ ^^^ ^^ ^^^^,. 

the middle of the body of the boue ; « b, body ; b, short process ; c, long process ; d, 
T^^,^^r,+v> +T,4r, ,^r,,.^ A4- ^^AA^-^r, ^,,4- ^^,^^.. processus lenticularis ;/, articular surface for 

beneath this part it widens out again {i^e head of the maiieus 

anteriorly into the important tooth 

which locks with the malleus in all its inward movements, and posteriorly 

into the descending ramus or long process. The articulation between the 

malleus and incus is a true joint, in which is found a meniscus.^ 

If this articulation is viewed on its outer surface, — i.e, on that side 
towards the external auditory canal, — it would seem that the incus quite 
overlapped or embraced the head of the malleus ; when viewed from its 

^ Sommering. ^ Glaserian fissure. ^ Henle, Eingeweidelehre, S. 745. 

* Ligamentum incudis posterius et ligamentum incudis superius. 

^ Henle calls this the incus-tympanic joint (Fig. 29, d), **an amphiarthrosis be- 
tween the articulating surface of the short process of the incus, and a prominence on 
the posterior wall of the tympanic cavity. The articulating surface on the incus is 
covered with a thin layer of fibrous cartilage." 

^ Eiidinger. 





30 DISEASES OF THE EAR. 

tympanic side, however, it appears that the largest share in the joint 
belongs to the malleus. This is due to the wonderfully peculiar structure 
of this joint, the true nature and function of which were first pointed 
out and explained by Helmholtz in 1869.^ 

Dimensions of the Incus. — The greatest length of the incus is in a ver- 
tical line passing from the top of the body of the bone through the long 
process. It measures seven millimetres. The horizontal upper edge of 
the body measures five millimetres. The greatest thickness — two and 
one-half millimetres — is at its articulating surface for the malleus. 

Malleo-incudal Joint — Before Helmholtz' s investigations, the shape of 
this articular surface was usually described as resembling a saddle. In 
order to gain a clearer idea of the mechanism of this joint, Helmholtz 
makes use of a different comparison. '' It is, in fact, like the joint used 
in certain watch-kej^s, where the handle cannot be turned in one direction 
without carrying the steel shell with it, while in the opposite direction it 
meets with only slight resistance. As in the watch-key, so here, the joint 
between hammer and anvil admits of a slight rotation about an axis 
drawn transversely through the head of the hammer towards the end of 
the short process of the anvil ; a pair of cogs oppose the rotation of the 
manubrium inward, but it can be driven outward without carrying the 
anvil with it.'' ^ It is of the kind of joint known as ginglymus. The 
mechanism of this joint is best understood when it is known that the 
malleus, as a whole, is a lever, the fulcrum of which passes just below the 
short process. This, of course, leaves the head and neck — i.e., the articu- 
lating surfaces for the malleo-incudal joint and all the free tympanic parts 
of the malleus — above the line of support of the lever, the manubrium 
being below. The latter is the long arm of the lever, and consequently 
all its movements are repeated in an opposite direction on the head of the 
malleus. Each inward movement of the manubrium, therefore, causes a 
slight outward motion in the head of the malleus and a firm locking of 
the malleo-incudal joint, by which the incus is carried about an axis 
drawn transversely through the head of the hammer towards the end of 
the horizontal or short process of the incus. The incus being also sus- 
pended as a lever about the line just named, when all above that line 
moves outward, all below the line moves inward, — i.e., as the upper part 
of the incus is moved outward the long process swings inward and carries 
the stapes ahead of it, thus forcing the foot-plate of the latter into the 
oval window. 

The Stapes, or Stirrup. — The smallest bone in the body and the inner- 
most of the three auditory ossicles is the stapes, or stirrup. Its name is 



^ Mechanik der Gehorknochelchen und des Trommelfells, Bonn ; also Pfliiger's 
Archiv f. Physiologie, 1 Jahrgang. 

2 Helmholtz' s Mechanism of the Ossicles of the Ear, etc., English translation by- 
Buck and Smith, 1873, p. 33. 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY. 31 

derived from the striking resemblance it bears to a stirrup. It is divided 
into a head, or capitulum, a neck, two branches, or legs fcrura), and a 
foot-plate, or base (Fig. 28). 

Fig. 28. 
A B 




Right stapes; magnified four diameters. (Henle.) A, from A^ithin ; B, from in front; C, from 
beneath ; b, foot-plate, or base ; d, capitulum, or head ; a, anterior ; p, posterior shaft or crus of 
stapes. 

The head, which is like a cup-shaped button, is placed at the junction 
of the two crura. It is designed for the reception of the processus len- 
ticularis of the incus, with which it forms a ball-and-socket joint. There 
is a meniscus in this joint, according to Eudinger.^ On the posterior 
surface of the head of the stapes the stapedius muscle is inserted. 

The two crura, or branches, are furrowed on their inner surface, which 
makes them lighter, yet does not deprive them of strength. They arise 
from the base, forming a graceful arch, and unite above in the head, as 
already stated. 

The foot-plate of the stapes is oval or slightly kidney-shape, thicker at 
the i^eriphery than in the centre, is slightly convex towards the vestibule, 
and concave on its tympanic surface ; it fits into the oval window, where 
it is held by a fibrous packing. This permits of a slight inward and out- 
ward movement on the part of the base of the stirrup. When the stapes 
is in position, the long axis of its base is horizontal and coincides with 
that of the oval window. In this position its convex edge looks upward, 
and its concave edge, which gives it its slight kidney-shape, looks down- 
ward (Fig. 28, A). 

The Jigamentum obturatorium stapedis is a thin membrane stretching 
across the space between the base and the crura ; it is attached to the 
crista of the former and the furrow on the inner edges of the latter.^ 

Dimensions of the Stapes. — The stapes measures nearly four millimetres 
from its head to the under surface of the foot-plate. The latter is two 
and a half millimetres long in its horizontal diameter, one millimetre in 
its vertical diameter (the bone, of course, must be imagined in normal 
position), and about one-fourth of a millimetre thick at its edges. It is 
slightly concave towards its centre. 

Joint between the Base of the Stirrup and the Oval Window. — According 

^ Yirchow's Archiv, 1860, Bd. xx. Monatsschr. f. Ohrenh., January, 1873. 
^ Riidinger, Atlas of Osseous Anatomy of the Human Ear, edited by C. J. Blake, 
Boston, 1874, p. 9. 



32 



DISEASES OF THE EAR. 



Fig. 29. 



to Helmlioltz,^ the base of tlie stapes is surrounded at its edge by a lip of 
fibro-elastic cartilage seven-tenths of a millimetre thick. The union be- 
tween the base of the stirrup and the wall of the labyrinth appears to be 
formed by means of the periosteum of the vestibule, extended over the 
base of the stapes (Henle), but the fibrous lip on the edge of the base of 
the stirrup is not attached to the fenestra ovalis. The mucous membrane 
of the tympanic cavity extends over the outer or tympanic surface of the 
base of the stapes. 

Gustav Brunner^ regards the malleo-incudal and incudo-stapedial 
joints as a variety of symphysis or synchondrosis. He is disposed to 
regard the connections between the ossicula auditus not as true or ordi- 
nary joints. As described by him, they are all of peculiar construction, 
since between the cartilaginous surfaces of the bones there is a fibrous or 
fibro- cartilaginous intermediate substance. 

Eiidinger ^ reasserted the true joint-like structure of the articulations 
of the ossicula. He also maintained his view that in both the malleo- 
incudal and incudo-stapedial joint there is a fibro- cartilaginous disk con- 
nected with the capsular ligament, but not 
with the hyaline covering of the articular 
surfaces of the bones. 

The Tymjpanum. — The tympanic cavity is 
about half an inch in height and width and 
a line or two deep, measuring from within" 
outward. It is lined with mucous membrane, 
which is reflected over all the tympanic con- 
tents, and is a continuation of that of the 
throat, nose, and Eustachian tube. The 
drum-cavity lies entirely within the temporal 
bone, and is bounded by a roof and floor and 
the four walls. 

The roof^ or tegmen tympani, is the boun- 
dary between the base of the brain and the 
tympanum. This osseous partition is very 
thin, and in some cases congenital fissures in 
it persist 5 in such instances the only boun- 
dary at the dehiscences, between the tympa- 
num and the cerebral cavity, is formed by 
the mucous membrane of the former and the membranes of the brain. 
It is evident that in such cases pathological processes in the drum-cavity 
are especially liable to pass upward to the brain. 




Right tympanic cavity viewed 
from above ; malleo-incudal and 
incudo-tympanic joints ; magnified 
two diameters. (Henle.) c, head of 
malleus ; e, short process of incus ; /, 
tendon of tensor tympani muscle ; 
d, capsule of incudo-tympanic joint ; 
a, ligamentum mallei anterius ; h, 
chorda tympani. 



^ Op. cit., pp. 34, 35. 

^ Ueber die Verbindung der GehSrknochelchen, namentlich, des Hammer- Am- 
bossgelenks, Vorlaufige Mittheilung. M. f. O., No. 1, 1872. 

3 Ueber die Gelenke der Gehorknochelchen, M. f. 0., No. 3, 1872. 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY. 33 

The Malleo-incuddl Joint and Surrounding Parts viewed from Above. — If 
the tegmen tympani be removed, let us say, from the right tympanic 
cavity, the malleo-incudal joint and the incudo- tympanic joint will be 
laid bare, and just in front of the head of the malleus, but below it, will 
be seen the tendon of the tensor tympani muscle coming upward and in- 
ward from the left, to be inserted into the tubercle on the neck of the 
hammer. Above this tendon, winding from within outward and to the 
right, around the neck of the malleus, is seen the chorda tympani on its 
way to the Glaserian fissure. Of course, this picture is to be reversed 
for the left ear. The suspensory ligament of the malleus is attached to 
the roof of the tympanic cavity (Fig. 30, 1). 



Fig. 30. 




Partial view of left drum-cavity and aditus from in front; the lowest portion of the cochlea, ves- 
tibule, and superior semicircular canal laid open by a vertical incision passing through the long axis of 
the latter, (Siebenmann.) 1, superior ligament of the malleus; '2, malleo-incudo-squamous space or 
attic ; 3, head of the malleus ; 4, margo tjnnpanicus ; 5, external ligament of the malleus ; 6, membrana 
flaccida ; 7, tendon of the tensor tympani ; 8, superior semicircular canal ; 9, long crus of the incus ; 10, 
handle of the malleus ; 11, auditory canal ; 12, promontory ; 13, tympanic cavity ; 14, floor of the drum- 
cavity ; 15, floor of the scala tjinpani (of the cochlea) ; 16, crista semilunaris (of the round window) ; 
17, inner opening of the aqua>ductus cochlese ; 18, lamina spiralis secundaria ; 19, fixation-pioint of the 
removed lamina spiralis primaria. 



The Attic, or Becessus Epitympanicus. — The removal of the tegmen 
tympani reveals the so-called attic, or recessus epitympanicus. The 
space is bounded above by the tegmen tympani, below by a plane run 
horizontally through the neck of the malleus, in front by the vertical 
plane passing through the processus cochleariformis for the tendon of 
the tensor tympani, and behind by the aditus ad antrum. Its inner 
boundary is the upper part of the inner wall of the middle ear above the 
promontory and plane of the tensor tympani, and its outer boundary is 
composed of the tympanic process or '^ scute" of the squama above and 

3 



34 



DISEASES OF THE EAR. 



the membrana flaccida below. Its cavity is occupied chiefly by the head 
and neck of the malleus and the body of the incus (Fig. 30^ 2). 

The Floor of the Tympanum. — The floor of the tympanum is not much 
more than a groove between the outer and inner wall. It is below the 
lower periphery of the drum-head, the opening of the Eustachian tube, 
and the opening into the mastoid cells. It is entirely within the boundary 
of the petrous portion of the temporal bone and over the jugular fossa. 

The Outer Wall of the Tympanum.— The outer wall of the tympanic 
cavity is composed mainly of the membrana tympani. The bony frame- 
work of the annul us tympanicus around the membrana tympani consti- 
tutes the limit of the outer wall of the tympanum. In connection with the 
outer wall — i.e., in it or on it — we find the manubrium mallei, the chorda 




Inner surface of the left membrana tympani 
(outer wall of tympanic cavity) and the attic, 
with the malleus head suspended in it. (Politzer.) 
Is, suspensory ligament of the malleus ; /, fold of 
the posterior pouch of the membrana tympani ; v, 
fold of the anterior pouch of the membrana tym- 
pani, and the anterior ligament of the malleus ; 
la, c, chorda tympani nerve. 




Diagrammatic representation of the formation 
of the so-called pouches of the membrana tym- 
pani. 1, mucous membrane of head of malleus ; 2, 
reflection of same over chorda tympani nerve ; 3, 
a pouch of the membrana t>-mpani ; 4, 4, inner 
surface of membrana tympani ; 5, section through 
osseous floor of tympanic cavity ; 6, umbo of 
membrana tympani ; 7, short process of malleus. 



tympani, and the duplicature of mucous membrane about it, which also 
forms the inner boundary of the so-called pockets of the membrana tym- 
pani. 

The pockets or pouches of the membrana tympani are the spaces lying 
between the upper part of the membrana tympani and the duplicature 
of mucous membrane around the chorda tympani nerve, in the so-called 
horizontal portion of its passage through the tympanic cavity. After the 
mucous membrane of the tegmen tympani has been reflected over the 
chorda tympani, it ascends again to reach the upper edge of the drum- 
membrane, in order to form the inner or mucous layer of the latter. 
Thus it is that the chorda tympani is found at the free edge of a fold 
of mucous membrane, which, with the membrana -tympani lying farther 
outward, forms a space or pocket open below. This space or groove lying 



ANATOMY AXD PHYSIOLOGY OF THE TYMPANIC CAVITY. 



35 



Fig. 33. 



between the aforesaid fold and the drum- membrane, by reason of the 
clinging of the chorda timpani to the inner sui'face of the neck of the 
malleus, is divided into two spaces, — an anterior, the smaller, and a pos- 
terior, a larger one, — called, re- 
spectively, the anterior and pos- 
terior pouch or pocket of the 
drum-membrane. They were first 
described by von Troeltsch, in 
1856, and are situated on the inner 
edge of the upper part of the 
drum-head (Fig. 32, 3). 

The iwsterior pouch lies be- 
tween the malleus and the poste- 
rior periphery of the membrana 
tympani. The shape of the poste- 
rior pouch is triangular or tent- 
like, the apex of which is directed 
inward and its base outward. It 
is about three millimetres high 
and four millimetres broad. This 
pouch is best seen when the inner 
side of the drum-head is viewed, 
but it can also be seen from 
the outer side when the drum- 
head is thin and pro^^eiiy illumi- 
nated. 

The anterior pouch lies in front 
of the malleus, and is smaller than 
the posterior i^ouch. Its inner 
wall is composed of mucous mem- 
brane only. It is not so well 
marked as that of the posterior 
pouch, but contains ^^all the parts 
which proceed from or enter the 
Glaserian fissure."' The anterior 
is much lower and shorter than 
the posterior pouch. 

There is a third pocket or pouch of the membrana tympani described 
by Prussak ^ and Gustav Brunner - ^Fig. 33, i). This cavity is bounded 
behind by the neck of the malleus, below by the upper surface of the 
short process of the hammer, in front by the membrana flaccida, and 




Section through the long axis of the malleus at 
right angles to the membrana tympani, from an 
adult. (Brunner.) t, bony ridge at the upper seg- 
ment of the drum-head (the segment of RiA-inus, ac- 
cording to Helmholtz) ; g, head of malleus ; p, neck 
of malleus ; o, handle of malleus ; I, short process ; 
j, membrana flaccida ; h. ligamentum mallei ex- 
ternum ; 772, chorda tympani ; n. tendon of tensor 
tympani ; i, a cavity, according to Prussak ; a, car- 
tilage ; 6, 6, fibres of membrana tympani ; c, der- 
moid layer of membrana tympani ; d, membrana 
propria ; e. Haversian canals. 



^ Archiv fiir Ohrenheilkunde, Bd. iii. 

2 The Connections between the Ossicles of Hearing, Archives of Oph. and Otol. 
1874, vol. iii. pp. 145-172. 



36 



DISEASES OF THE EAR. 



above by a ligamentous band, the ligamentum mallei externum, which is 
inserted between the margo tympanica and the spina mallei. The cavity 
is separated from the anterior tympanic pouch by the upper blind end of 
the latter ; posteriorly, it communicates with the tympanic cavity by a 
good-sized opening, above the position of the posterior tym^Danic pouch. 
This pouch, being thus placed in communication with the tympanum, 
may become filled with mucus or pus, and may, in consequence, be rup- 
tured. 

Many cases of earache which present no features of distention of the 
drum-head proper nor, in fact, of the region of the membrana flaccida 




k I mnop q r s 
Inner wall of the left tympanic cavity, natural size ; photograph from nature, a, mouth of Eu- 
stachian tube ; b, belly of tensor tympani muscle ; c, tendon of same above tympanic mouth of Eusta- 
chian tube ; d, middle cranial fossa ; e, tegmen tympani ; /, recessus epitympanicus, or attic ; g, aditus 
ad antrum ; h, tympanic antrum ; i, middle cranial fossa ; I; carotid canal ; I, anterior wall of tym- 
panic cavity ; m, promontory, inner tj-mpanic wall ; n, floor of tj-mpanic cavity ; o, jugular bulb ; p, 
stapes in oval window ; q, round window ; r, stapedius muscle in its cone, latter laid open ; s, Fallopian 
canal laid open ; t, upper part of outer mastoid surface ; u, section of mastoid cortex ; v, w, mastoid 
cells ; X, mastoid cortex ; y, mastoid process. 



may be relieved instantly by i)uncturiug the latter at the third pouch. 
The jjointof the puncturing in such cases is just above and in front of 
the short process. 

As a general rule, when there is severe earache, attended only by 
redness of the flaccid part of the drum-head, and neither congestion nor 
bulging of the drum-head proper, a cut into the congested flaccid part 
will relieve the suffering. Mucus or pus will usually escape ; sometimes 
only blood. 

The Inner Wall of the Tympanum. — On the inner wall of the tympanic 
cavity there is found a convexity, the promontory caused by the projec- 
tion outward at that point of the lower turn of the cochlea (Fig. 34, m). 
This eminence is usually seen through the membrana tympani as a pale 



ANATOMY AND PHYSIOLOGT OF THE TYMPANIC CAVITY. 37 

yellowish spot. At this point the inner and outer walls of the tj-mpanum 
are closest to each other. Above the promontory, in a depression named 
the fossuJa fenestrce ovaJis (Eiidinger), is the oval window, fenestra ovaliSj 
which receives the foot-plate of the stapes (Fig. 34, j^). Behind the 
promontory is the niche in which is found the round window, fenestra 
rotunda (Fig. 34, q). The long diameter of the oval window is three mil- 
limetres and its short diameter 1.7 millimetres. The diameter of the 
round window is two millimetres. A ridge starts above the oval window 
and curves backward and downward behind the promontory and round 
window. This ridge is the posterior limit of the inner wall of the 
tympanum, and marks the position of the canal for the facial nerve 
(Fig. 34, s), which escapes from the tympanum at the stylomastoid 
foramen. The course of the facial nerve to the ear will be considered 
farther on. 

Eminentia Staiyedii. — Behind, and a little below the line of the oval 
window, is a bony eminence, the eminentia stapedii (Fig. 34, r). This 
little conical eminence is hollow and contains the stai)edius muscle, to 
which it gives origin. The tendon of 
this muscle, after passing through a 
small opening in the apex of the emi- 
nence, runs a little upward and forward, 
forming an obtuse angle with the long- 
axis of the muscle, and is then inserted 
into the edge of the articular surface 
of the head of the stapes.^ The sta- 
pedius muscle is supplied with a branch ' 
from the facial nerve (Fig. 35, ms). " J ^>p<s;^-533i:!i:^.^4^^ , 

Function of the Stapedius Muscle. — I ^?ii^' ^ 

According to Henle,^ it is j)robable that '"" ^' 

the stapedius muscle serves to hold the ^^T^^^^XSTZTS^I 

stapes in a firm position rather than to twice the natural size; right ear. (Politzer.) 
move it, and that it acts only when •'^'' stapes; cs head of the stapes; ms, sta. 
? "^ pedius muscle m its canal and its tendon in- 

there is danger that an undue force serted at the neck of the stapes ; p, promon- 
COmmunicated to the malleus will be tory ;/. facial nerve m the descending part 

of the facial canal ; v, artificial opening into 

conveyed to the stajDCS by means of vestibule. 

the intervening incus. Its action then 

is to prevent the stapes from being forced into the oval window, and also 

to antagonize the tensor tymj^ani muscle. 

Fixator Baseos Stapedis. — Eiidinger has described an organic muscular 
structure on the tympanic surface of the stapes, which he calls the 
fixator haseos staj^edis. It arises from a small bony ridge (diameter 0.8 
millimetre), situate one millimetre from the upper and posterior circum- 
ference of the oval window, and is inserted into the angle formed by the 

^ Henle. ^ Eingeweidelehre, S. 749. 




38 DISEASES OF THE EAR. 

leg of the stapes and its somewhat projecting foot-plate. It is supposed 
to be an antagonist of the voluntary muscle, the stapedius.^ 

Topographical Belation of the Stapedius 31uscle to the Facial Nerve. — In 
the foetus only the upper part of the stapedial cavity is separated from 
the facial canal by bone, the lower part having free communication with 
the canal. ^ At this point the soft tissues surrounding the muscle and the 
nerve are in contact. In the adult, however, the communication between 
the bony cavity containing the muscle and the facial canal is less free, 
being effected by means of one or more small openings or by one long, slit- 
like aperture from three to five millimetres long and one-half millimetre 
wide. Transverse sections of this muscle show that it is a triangular 
prism ] longitudinal sections show that its general form is pear-shaped. 

The oval window is separated from the round window by the tract of 
bone corresponding to the x;)osterior surface of the j)romontory. They 
are about two millimetres apart. The plane of the former looks outward, 
and is nearly vertical in its position 5 that of the latter looks backward 
and downward. The oval window is the entrance to the vestibule and 
mediately to the cochlea. The round window is an exit from the cochlea 
into the tympanic cavity. This window, however, in its normal state, is 
hermetically closed by a membrane, the memhrana tympani secimdaj-ia, or 
membrana fenestrse rotundse. 

Well forward, on the inner wall, towards the tympanic opening of the 
Eustachian tube, are the processus cochleariformis, the spoon-shaped tym- 
panic end of the septum tubce, which separates the Eustachian tube from 
the bony furrow containing the tensor tympani muscle, and the tendon 
of the latter as it passes to the malleus (Fig. 36, d). The processus cocli- 
leariformis is the fulcrum over which the tendon of the tensor tympani 
plays. 

Tensor Tympani Muscle. — This muscle originates from the anterior 
mouth of the canalis musculo-tuharius of the pyramidal portion of the 
temporal bone, the upper wall of the cartilage of the Eustachian tube, 
and from that small portion of the sphenoid bone which joins the tem- 
poral bone, the processus angularis. The muscle then passes over the 
septum tuhce and enters the semi-canalis tensoris tympani^ (Fig. 34, a, 
h, c). Its tendon passes over the processus cochleariformis, and, turning 
outward, crosses the tympanic cavity at right angles to the belly of the 
muscle, to be inserted into the malleus (Fig. 36, d). The tensor tym- 
pani is connected with the dilatator tubse, or tensor palati, by both tendi- 
nous and muscular fibres, as shown by Kessel, Eiidinger, Mayer, Eebsa- 

^ Das hiiutige Labyrinth, by Eiidinger, Strieker's Handbuch, 1872, Ss. 912, 913. 

2 Politzer, Zur Anatomie des Gehororgans, I. Ueber das Verhaltniss des Muse. 
Stapedius zum nervus faciahs ; 11. Ueber den Processus Styloideus, Arehiv f. Ohrenh., 
Bd. ix. S. 158. 

^ This canal is not always perfectly closed, and hence it has been called the semi- 
canalis tensoris tympani. 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY 



39 




men, and others. The motor nerve of the tensor tympani is derived 
through the otic ganglion^ from the motor root of the trigeminus. ^ 

The tensor tympani muscle has been described as a penniform muscle,' 
in allusion to its appearance, due to the fact that the muscular fibres arise 
from the periosteum of the upper wall 
of the bony canal in which the muscle 
lies, and pass into the tendon which lies 
on the under edge of the muscle ; the 
latter is turned towards the floor of the 
canal. As the fibres of the muscle are 
short, a large portion of the tendon is 
within the canal, where the muscle is 
covered by a periosteal sheath that is 
continued over the free portion of the 
tendon, crossing the tympanic cavitj^, 
and is there covered with mucous mem- 
brane. 

The transverse section of a perfect 
tensor tympani muscle measures 2.75 
millimetres, the length of its tendon 
from the processus cochleariformis to the 
insertion into the malleus is 2.25 milli- 
metres, and the length of the muscle from 
its extreme origin in the Eustachian tube 
to the turn of the processus cochleari- 
formis is 2.2 centimetres, somewhat more 
than an inch, as shown by Weber-Liel. 
The tendon of the tensor tympani is in- 
serted on the anterior surface of the inner 
edge of the manubrium rather than on 
its posterior surface ; hence traction inward of the muscle will cause a 
rotation of the malleus about its long vertical axis, and thus twist the 
posterior surface of the handle of the malleus outward, and with it the 
posterior segment of the membrana tympani. It therefore often seems, 
in certain pathological retractions of the malleus, that the anterior seg- 
ment of the membrana tympani is sunken and the anterior outline of 
the manubrium especially prominent. 

Anterior and Posterior Walls of the Tympanic Cavity. — The most im- 
portant point in the anterior wall is the tympanic opening of the Eusta- 
chian tube, situated considerably above the floor of the tympanum, an 
arrangement which often produces a retention of small amounts of fluid 
in the cavity (Fig. 34, I). 



Left auditory apparatus viewed from 
above ; tegmen tympani and upper part of 
the labyrinth removed ; natural size, from 
photograph, a, internal auditory canal, 
for auditory nerve ; 6, cochlea cut through 
its modiolus ; c, membrana tympani ; d, 
cochlear process for tendon of tensor tym- 
pani passing to the membrana ; e, malleo- 
incudal joint ; /, mastoid process, outer 
surface ; g, upper mastoid cells ; h, middle 
cranial fossa, outer back part ; i, vestibule ; 
k, section through posterior semicircular 
canal; I, aditus ad antrum; vi, mastoid 
cells ; n, antrum. 



^ Henle, Eingeweidelehre, S. 747. 

2 Ludwig and Politzer, Meissner's Jahresbericht, 1860, S. 583. 



Helmholtz. 



40 



DISEASES OF THE EAE. 



In the posterior wall of the tympanic cavity is situated the important 
opening communicating with the mastoid antrum, and by that means with 
the mastoid cells. The tympanic or mastoid antrum is a cavity of irregu- 
lar shape, the roof of which is a continuation backward of the tegmen 
tympani (Fig. 34, h, and Fig. 36, n). It is formed by a hollowing out of the 
base of the pyramidal part of the temporal bone, which is joined to the 
mastoid portion at the upper part of the latter. This cavity may extend 
forward into the root of the zygomatic arch and downward into the mas- 

FiG. 37. 




Fig. 38. 



AR. CRIB. SUP. 



Cast of the soft parts of the middle ear, viewed from without : the cartilaginous portion of the 
Eustachian tuhe is not included. (Siebenmann.) 1, attic of the drum-cavity in front of the plica 
transversa ; 2, plica transversa ; 3, posterior superior horizontal cells ; 4, large solitary cell, including 
nearly all the mastoid process ; 5, handle of the malleus ; 6, cells on the floor of the Eustachian tube ; 
-7, large penniform cell of the inner wall of the Eustachian tube ; 8, isthmus of the Eustachian tube. 

toid cells. It communicates with the tympanum by means of a wide 

opening, the under edge of which is about on a level with the oval window. 

The floor of the tympanic cavity rises back- 
ward to meet this opening, in the same way as 
it rises anteriorly to the opening for the Eusta- 
chian tube (Fig. 37, 1-4). 

Course of the Facial Nerve. — Although the 
facial canal has been already mentioned in 
connection with the inner wall of the tym- 
panum, further attention should be given at 
this point to the course of the facial nerve 

and the important relations it sustains to the structures in the posterior 

portion of the tympanum and to the mastoid cells. 

The /acmZ canal rises at the fundus of the internal auditory canal (Fig. 

38), and after leaving it, it passes somewhat in front of and farther out- 



CRISTA FALCIF. 



FOR. CENT.COCH 




TPACT. SPIR. FORAM 

Nerve foramina at the fundus of the 
internal auditory canal. (Quain.) 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CA\TTY 



41 



ward than it, between the cochlea and the semicircular canals, above the 
roof of the vestibule (Fig. 39, a-g). Upon reaching the plane of the 



Fig. 39. 




Tympanic cavity after removal of the teg- 
men tympani and some of the hone anteriorly 
and interiorly ; course of facial nerve ; left side. 
(Politzer.) ha, malleo-incudal joint; t, ten- 
sor tympani muscle ; s, tendon of the tensor 
tympani passing across the tympanum ;/, facial 
nerve ; a, auditory nerve ; g, geniculate gan- 
glion ; n, greater superficial petrosal nerve ; an, 
mastoid or tympanic antrum. 



inner wall of the tympanic cavity, 
it turns' suddenly backward at right 
angles to its former course, and, run- 
ning above the position of the oval 
window, curves gradualh^ backward 
and downward, to escape from the 
tympanic cavity at the stylomastoid 
foramen in the postero-exterior sur- 
face of the petrous bone (Fig. 34, s). 
In the anterior wall of the facial canal, 
very near the stylomastoid opening, 
is a small foramen leading to the 
canalis chordce, which, leaving the 
facial canal, runs upward and forward 
through the substance of the i^etrous 
bone to the tymiDanum, in the lower 
external corner of which it opens. 

Greater Superficial Petrosal Nerve. — 
The greater superficial nerve, one of the posterior branches of the 
sphenopalatine, or Meckel's ganglion, runs in a groove on the posterior 
surface of the petrous portion of the temporal bone, and, entering the 
hiatus Fallopii, passes along the Fallox^ian or facial canal to the genicu- 
late ganglion (Fig. 39 n, g) of the facial nerve. Strictly' speaking, this 
nerve runs from the facial nerve to the sphenopalatine ganglion, forming 
its motor root. (Gray.) The other nerves joining the geniculate ganglion 
are the small superficial petrosal, from the otic ganglion, and the external 
superficial petrosal, from the sympathetic on the middle meningeal artery. 

Lympliatie Cavity in the Facial Canal. — On the inner side of the facial 
canal, Eiidinger ^ has described an empty space lying between the nerve- 
trunk and the periosteum. The supposition is that this space marks an 
extension of the arachnoidal sac of the brain into the canal of the facial 
nerve, and is similar to that which is known to accompany both the optic 
and the acoustic nerve ; it may therefore be regarded as a lymph cavity. 

The Chorda Tympani Nerve. — The chorda tympani has always been de- 
scribed as a branch of the facial nerve, though there is much to lead to a 
doubt that it has such an origin. It may be a separate nerve. 

Nerves supplying the 2Iucous Membrane of the Tympanic Cavity. — The 
nerves supplying the mucous membrane of the tympanic cavity, as well 



^ Genu canalis faded is, at which point the canal for the great superficial j)etrosal 
nerve joins the facial canal. (Henle. ) 

^ Feber den canalis facialis in seiner Beziehung, zum siebenten Gehirnnerven 
beim Erwachsenen, M. f. O., 1873, No. 6. 



42 



DISEASES OF THE EAR. 




as that of the Eustachian tiihe and mastoid cells, are derived from the 
tympanic nerve, also called the tympanic plexus, an anastomosis between 
the otic ganglion, petrosal ganglion of the glossopharyngeal nerve, and 
the carotid plexus, by means of the superior cervical ganglion of the 

sympathetic nerve/ 

The otic ganglion (Arnold's) (Fig. 
40, 7) is situated on the inner side 
of the sensory division of the inferior 
maxillary nerve, and sends several 
small branches to it. From the otic 
ganglion emanates also the small pe- 
trosal nerve that joins the facial 
nerve and the tympanic branch of 
the glossopharyngeal nerve (Fig. 
40, 5). The tympanic nerve, further- 
more, sends branches which anasto- 
mose with the smaller and greater 
petrosal nerves. The latter branch 
is also in connection with Meckel's 
ganglion. The external petrosal 
nerve is in connection with the sym- 
pathetic nerve on the middle menin- 
geal artery. It is important to bear 
these relations in mind when consid- 
ering certain neuralgias in and about 
the ear, which might otherwise prove 
very puzzling. 

Numerous cases of earache are 
constantly seen which are solely due to imperfect teeth. This may be 
explained by the fact that by means of the otic ganglion, the soft palate, 
the drum-head, and the tensor tympani muscle, the lining membrane of 
the cavity of the tympanum, the integument of the external ear, and the 
teeth are put in sympathetic relation with one another. 

Perhaps certain epileptiform phenomena which have been observed in 
connection with well-marked disease of the middle ear, as well as similar 
phenomena which could be seen to be connected with disease of the ex- 
ternal ear, may be explained by reflex communication through the 
tympanic plexus. 

The tymjoanic nerve, or Jacobson's nerve, is a branch from the petrosal 
ganglion ^ of the glossopharyngeal nerve 5 "it enters a small bony canal 
on the base of the petrous portion of the temporal bone (Fig. 13), ascends 
to the tympanum, enters this cavity by an aperture in its floor close to 



'20 

Nerves in and about the tympanum. 
(Heath.) 1, sensory portion of the fifth nerve 
with Gasserian ganglion ; 2, tensor tympani mus- 
cle ; 3, motor portion of the fifth nerve passing 
beneath the ganglion ; 4, malleus ; 5, small super- 
ficial petrosal nerves of Arnold ; 6, incus ; 7, otic 
ganglion ; 8, facial jieTxe ; 9, chorda tympani ; 
10, membrana tympani ; 11, tensor palati muscle ; 
12, middle meningeal artery ; 13, 13, lingual 
nerve ; 14, auriculo-temporal nerve ; 15, inferior 
dental nerve ; 16, pterygoideus externus ; 17, 
pterygoideus internus ; 18, internal maxillary 
artery ; 20, 20, mylohyoid nerve. 



^ Bischoff, Microscopische Analyse der Kopfnerven, Miinchen, 1865. 
2 Andersch. 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY. 43 

the inner wall, and divides into three branches, which are contained in 
grooves upon the surface of the promontory." ^ This is the largest nerve- 
branch given to the tympanic cavity, and therefore it has received its 
special name and consideration. Since, however, the tympanic nerve 
contains so large a number of large ganglion cells, either solitary or 
grouped, and thus makes numerous connections with other important 
ganglia and nerves, the name tymimnie plexus is now given to what for- 
merly was called, in its tympanic portion at least, the tympanic nerve. 

Blood-vessels of the Tympanic Cavity. — The chief artery of the tympanic 
cavity runs along the floor of the tympanum and over the promontory. 

According to Gray, the arteries supplying the tympanic cavity are as 
follows : the tympanic branch of the inferior maxillary, which is given to 
the memhrana tympani, the stylomastoid branch of the posterior auricular, 
distributed to the back part of the tympanic cavity and mastoid cells, a 
number of smaller branches from the petrosal branch of the middle menin- 
ffcal, and branches from the ascending pharyngeal and internal carotid. 
The veins of the tympanic cavit}" terminate in the middle meningeal and 
pharyngeal veins, which form a plexus near the glenoid articulation, and 
then empty into the internal jugular vein. 

Zuckerkandl ^ has described an artery which he has termed the arteria 
stapedia. This artery is a branch of the stylomastoid artery, that enters 
the tympanum through an ever-i)resent triangular opening in that part 
of the facial canal just above the fenestra ovalis. This small vessel 
descends through the membrana obturatoria of the staj^es, either to anas- 
tomose with a branch of the artery following Jacobson's nerve or to 
break up into secondary anastomoses before it reaches this point. Before 
the artery passes the stapes it gives off a branch to the anterior crus of 
the stapes and to the anterior part of the membrana stapedia, which it 
divides in two, a second branch to the hinder crus, and to the posterior 
part of the stapedial membrane, and a third arteriole, usually from one 
of the lateral branches, passes inward to the foot-plate of the stapes. 

PHYSIOLOGY. 

The function of the tensor tympani muscle is somewhat like that of 
the palmaris,^ — i.e., better adapted for tension than for motion. It also 
appears that, by exerting a slight tension on the membrana tympani, this 
muscle can bring about a muffling or damping effect without any visible 
movements in the ossicles. 

In 1860 Politzer ^ showed that the tensor tympani ^^as supplied by a 
branch of the motor division of the fifth nerve. 

1 Gray. 

^ Ueber die Arteria Stapedia des Menschen, Monatsschr. f. O., Xo. 1, 1S73. 

^ Henle, op. cit., p. 748. 

^ Meissner's Jahresbericht, S. 583. 



44 DISEASES OF THE EAR. 

Later, Yoltolini ^ performed a series of experiments with electricity on 
the trigeminus. He showed that the tensor tympani can be put into 
motion by excitation of these two cerebral nerves, and he used this fact 
as an explanation of the power the muscle has of both voluntary and in- 
voluntary movement. Then arises, as Yoltolini suggests, the important 
question whether the fibre from the facial nerve, supplying the tensor, 
also passes through the otic ganglion, or goes directly from the facial to 
the muscle ; in the latter case the muscle would evidently possess power 
of voluntary motion. Although no one has demonstrated that a branch of 
the facial nerve does pass directly to the tensor tympani, the muscle cer- 
tainly possesses power of voluntary contraction, as held by Johannes 
Miiller, Yoltolini, and others. 

In this connection it must not be forgotten that the tensor tympani 
muscle is closely related to the muscular structures of the Eustachian 
tube. The latter obtains innervation from the glossopharyngeal nerve, 
and by this means also the tensor tympani muscle may obtain some of its 
nerve-supply from this sensori- motor nerve. 

Fhysiological Nature of Certain Tympanic Bands, heretofore considered 
Fathological. — Urban tschitsch ^ has pointed out the physiological nature of 
certain membranous and cord- like adhesions in the cavity of the tym- 
panum, which have heretofore been considered pathological. 

Function of the Found Window and its Menibrane. — In 1871 1 made some 
investigations into the condition of the membrana secundaria, or the 
membrane of the round window, during the movements of the ossicles of 
hearing, and the excursions performed by it were measured under the 
microscope. During these investigations I also noticed the effect of vary- 
ing labyrinthine pressure upon the small bones of hearing and the mem- 
brane of the round window. All the observations were made upon tem- 
poral bones from human subjects as soon as possible after death. During 
these observations one preparation was found that did not respond to the 
notes of the organ-pipes as the previous ones had done. The ossicula 
auditus manifested some very slight vibratory motions, but the membrane 
of the round window showed none. In order to explain this ai)parently 
abnormal result, and to find out whether an increased or diminished 
labyrinthine pressure could have produced it, the following experiments 
were instituted : 

Upon a perfect petrous bone, which failed to respond to the sounds 
produced by the already mentioned organ- pipes, the superior semicircular 
canal was opened at its summit, and to this opening one end of a small 
glass tube, one centimetre long by five millimetres wide, was hermetically 
sealed. The bone thus modified was placed in water and brought under 

^ Virchow's Arcliiv, Bd. Ixv. S. 467. 

2 Beitrage zur Entwickelungsgeschichte der Paukenhohle. Report of Royal 
Academy of Sciences, Vienna, January, 1873. 



ANATOMY AND PHYSIOLOGY OF THE TYMPANIC CAVITY. 45 

the air-pump, in order to remove any air which might have entered the 
labyrinth. After these arrangements the glass tube, sealed to the supe- 
rior semicircular canal, was connected by a gutta-percha tube, of similar 
diameter, to a reservoir of water, consisting of a funnel placed in a retort- 
holder, and which could be elevated or depressed at will. The pressure 
exercised by the water upon the labyrinth could easily be seen with the 
unaided eye, as the varying height of the funnel caused the column of 
water to press with greater or less force upon the membrane of the round 
window. 

With these modifications, the preparation, which formerly failed to 
respond to the notes of the organ-x^ipes, was placed in connection with 
the sources of sound, and the chain of bones, as well as the membrane of 
the round window, was observed during the passage of a note to the ear. 

The desired excursions now became apparent upon the hitherto ab- 
normal specimen, and resembled those upon other preparations, so long 
as the pressure was maintained at a certain grade ; but when increased or 
diminished beyond a given point, the excursions upon the ossicles and 
the membrane of the round window ceased. This cessation ivas observed to 
take place sooner during tlie occurrence of high than of low and powoful 
notes. 

The human ear, in the living state, sometimes fails to i)erceive high 
notes, while lower ones are distinctly heard. Perhaps such phenomena 
may be explained by an application of the results obtained in these in- 
vestigations, in which artificial labyrinthine pressure interfered with the 
action of the chain of ossicles and the membrane of the round window 
sooner in connection with high notes than with lower ones. 

In cases of hemorrhagic or serous effusions into the internal ear it 
may be supposed that the accumulation of pathological fluids in the laby- 
rinth interferes with the action of the chain of bones and the mem- 
brane of the round window, just as the artificial pressure did in my 
experiments. 

In addition to these destructive changes, which follow pathological 
processes in the ear, the perilymph of the labyrinth may be subject to 
great fluctuations in its amount, since the arachnoid sac and the labyrinth 
are intimately connected, as experiments of Weber-Liel^ and Hasse^ 
show. 

The following deductions may be di-awn from the author's experi- 
ments : 

1. The excursions of the chain of ossicles of hearing bear a fixed 
relation to one another. 

2. The excursions of the ossicles of hearing are communicated through 
the labvrinthine fluid to the membrane of the round window. 



iM. f. 0., August, 1870. 

^ Anatomische Studien, ISo. 19, S. 



46 DISEASES OF THE EAR. 

3. The excursion of the membrane of the round window generally 
equals that of the stajDes ; but it may equal that of the membrana tym- 
pani, at the lower end of the manubrium mallei. 

4. The pressure within the labyrinth, increased beyond certain limits, 
causes cessation of the action of the membrane of the round window and 
the chain of ossicles of hearing. This occurs sooner in connection with 
high notes than with the lower notes of the scale. 

5. If the labyrinthine pressure is greatly diminished or totally re- 
moved, the chain of ossicles may continue to vibrate, but they exert no 
influence upon the membrane of the round window. 

6. The vibrations of the membrane of the round window vary from 
ToW to T^h of a millimetre.^ 

A difference of opinion has existed respecting the part the membrane 
of the round window plays in the conduction of sound. Without doubt 
the excursions of the ossicles of hearing are conveyed through the water 
of the labyrinth to the membrane of the round window, as shown by the 
experiments of A. H. Buck and of the author, and later by the corrobo- 
rative experiments of Weber-Liel. 

The Fower of Muscular Accommodation. — According to Lucae's experi- 
ments,^ the ear has, in the tensor tympani and stapedius muscles, an ap- 
paratus for accommodating itself to various sounds. The first muscle 
aids in the accommodation for low musical tones, the latter accomplishes 
the same for high unmusical sounds. 

Abnormal contraction of the tensor tympani, with insufficient antag- 
onism of the stapedius, produces a modification of perception, termed 
by Lucae ' ' low hearing ;' ' an analogous condition of the stapedius muscle 
in its relation to the tensor tympani produces '^ high hearing." 

' All the measurements I obtained may be found recorded in the Archives of Oph. 
and OtoL, 1872. 

^ Die Accommodation und Accommodationsstorungen des Ohres. A. Lucae, Ber- 
liner Klin. Wochenschrift, 1874, No. 14. Abstract by Jacoby, Archiv f. O., Bd. ix. 
Ss. 184, 185. 



CHAPTEE Y. 

THE ANATOMY AND PHYSIOLOGY OF THE EUSTACHIAN TUBE 

AND MASTOID. 

ANATOMY. 

The Eustachian tube, though discovered by Vesalius, gets its uame 
from Bartolommeus Eustachius,^ who gave a more complete description 
of it than any of his contemporaries or predecessors. Though it is gen- 
erally conceded that Yesalius was the discoverer of the tube, some authori- 
ties think that even Alcmeon ^ and Aristotle ^ knew of its existence. 

The Eustachian tube is the only means of aerial communication be- 
tween the pharynx and middle ear. It opens into the pharynx a little 



C3D 











Castof the left middle-ear cavities, viewed from without. (Siebenmann.) 1, superior malleo-incudal 
fold ; 2, upper malleo-incudal space : 3, Prussak's space, superior pouch ; 4, exterior malleo-incudal 
fold ; 5, 6, exterior superior cells of the squama ; 7, 8. posterior superior horizontal cells of the mas- 
toid ; 9, inferior malleo-incudal space ; 10, cells of the mastoid process : 11, facial nerve ; 12, jugular 
bulb ; 13, Rosenmiiller's fossa ; 14, wall of the pharynx ; 15, carotid artery, with carotid sinus in white ; 
16, Eustachian tube : 17, floor of the drum-cavity ; 18, tubal cells : 19, internal carotid artery. 

above the floor of the nose, and passes backward, upward, and outward 
to the cavity of the tympanum, forming an angle of forty degrees with 
the horizon and one hundred and thirty-five degrees with the axis of the 
external auditory canal. The pharyngeal mouth of the tube is wide, but 



1500-1574. 



570 B.C. 



3 384-322 B.C. 



47 



48 DISEASES OF THE EAR. 

the tube narrows rapidly to the isthmus, from which point it widens again 
to the tympanic cavity. It therefore resembles, somewhat, two short and 
wide-based cones, placed point to point, their junction marking the posi- 
tion of the isthmus. The pharyngeal mouth of the tube is oval in shape, 
being nine millimetres high and five millimetres wide. At the isthmus, 
the junction of the osseous with the cartilaginous part of the tube, the diam- 
eter is from one and one-half to two millimetres, and the greatest diameters 
of the osseous canal vary from four to four and one-half millimetres. 
The entire length of the Eustachian tube is thirty-five millimetres, one 
and three-eighths inches, the bony portion being eleven millimetres and 
the cartilaginous part twenty-four millimetres long (Fig. 41). 

Bony Portion of the Eustachian Tube. — As already stated, the Eustachian 
tube is composed of a bony and a cartilaginous portion. The former lies 
entirely within the petrous bone;^ the latter portion is joined to the 
former and is about two-thirds of the entire tube. The caliber of the 
bony portion is triangular ; the angles, however, are rounded by the 
mucous lining of the tube. Its average diameter is about two millimetres. 
The outer wall of the three composing this triangular bony tube belongs 
to the pars tympanica, the inner wall separates the tube from the carotid 
canal, and the upper wall is formed internally by the septum tubse and 
the floor of the canal for the tensor tympani, and outwardly it unites with 
the outer wall of the bony tube in the petrotympanic or Glaserian fissure. 
The posterior wall of the bony portion of the canal is somewhat longer 
than the anterior wall. Usually the bony Eustachian tube is twice as 
wide as the semi- canal of the tensor tympani, but in some instances these 
relations are reversed, as shown by Eiidinger. 

Cartilaginous Portion of the Eustachian Tube. — In order to understand 
the true form of this part of the Eustachian tube one must imagine a 
shell of cartilage, not quite an inch long, bent so that a section of it at 
right angles to its long diameter resembles a hook or shepherd's crook. 
The longer portion of this section of cartilage will represent a section of 
the inner wall, the shorter portion represents that of the anterior or outer 
wall, and the curve shows the position of the roof of the Eustachian tube 
(Fig. 42, 8). It will be seen, therefore, that this part of the tube is not a 
complete and round cartilaginous canal, but rather a flattened tube, the 
posterior wall and roof of which are made entirely of cartilage, while the 
anterior wall is of cartilage only in its upper part, its lower portion being 
muscular ^ and completing the tube. The upper part of the inner cartilagi- 

^ In some cases the large wing of the sphenoid bone unites in the formation of the 
osseous part of the Eustachian tube, or at least it forms, with the pars petrosa, the 
sulcus petrosphenoidalis for the reception of the cartilage of the tube. (Riidinger, 
Die Ohrtrompete, S. 2. ) 

2 Formerly this part of the canal was called membranous, but, since muscular 
tissue is so intimately concerned in its formation, Riidinger proposes to call it muscular, 
as being more truly descriptive. 



AXATOMY AXD PHYSIOLOGY OF THE EUSTACHIAN TUBE. 



49 



nous wall, as well as the roof of the tube, is fastened to the base of the 
skull by means of the basilar fibro- cartilage (Fig. 42, 9). The lower 
end of the inner wall is movable. That part of the cartilage of the Eu- 
stachian tube which curves forward to form the upper part of the outer or 
anterior wall of the tube is widest and most movable in its middle por- 
tion ; it is narrower and more firmly fixed at its two extremities, — ^viz., 

Fig. 42. 




-O 



:^^ ^";r^ 



-7 






^fjf ^ 





-^-O' cSJ 





Transverse section through the middle of the Eustachian tube, slightly magnified. (Siebenmann.) 
1, larger superficial petrosal nerve ; 2, carotid artery surrounded by carotid sinvis ; 3, venous plexus ; 4, 
mucous glands of the inner tubal wall ; 5, mucous glands of the outer tubal wall ; 6, tongue-shaped 
projection of the lower edge of the inner tubal cartilage ; 7, levator veli muscle ; 8, fat embedded in 
the fibrous mass fixing the cartilaginous tubal hook to the base of the skull ; 9, basilar fibro-cartilage. 



above, where it is joined to the jagged bony edge of the osseous canal, 
and below, to the jiterygoid process. 

The caliber of the tube, in the main, is not round, but cleft-like, and 
slightly sigmoid in shai:)e ; however, that portion of the caliber lying in 
the curve formed by the cartilage as it tui^ns forward — i.e., that part 
lying entirely within cartilaginous boundaries — is round and more open 
than the rest of the lumen of the tube, owing, probably, to the stiffness 
of the cartilage (Fig. 42, 4 and 5). This fact will always insure at least 

4 



50 DISEASES OF THE EAR. 

a portion of tlie tube's being more likely to be free from obstructions or 
from having its two sides stick together. To this more patulous part 
Eiidinger has given the name of safety-tube (Sicherheitsrohre), and to the 
cleft-like« caliber of the tube below this rounder lumen he has given the 
name of ''accessory cleft" (Hilfsspalte), ''since^ according to Du Bois 
Eaymond, these terms express most clearly their physiological impor- 
tance."^ The posterior cartilaginous wall of the Eustachian tube projects 
well into the pharnyx, forming there a prominent ridge, the anterior 
boundary of the fossa of Eosenmiiller. Into the latter the Eustachian 
catheter is often placed in mistake for the pharyngeal mouth of the Eu- 
stachian tube. When the latter is to be catheterized, this prominent 
ridge, marking the termination of the cartilage of the Eustachian tube, 
should be sought for and thoroughly located with the beak of the catheter. 
In order to do this it is well to allow the catheter to pass first into the 
fossa of Eosenmiiller, then to glide gently forward over the aforesaid car- 
tilaginous lip, by which act the beak can hardly escape going into the 
pharyngeal mouth of the tube. 

As already stated, the cartilaginous shell of the Eustachian tube is 
adherent at its curve or roof to the base of the skull by means of the 
basilar fibro - cartilage ; the edges of the shell — i.e., the edges of the an- 
terior and posterior lips of the cartOage of the tube — are free, and from 
them important muscular structures arise. The inner dilator of the tube, 
or the salpingo-pharyngeus muscle, is one of these, and arises from the 
edge of the posterior cartilaginous wall of the Eustachian tube, and 
passes towards the superior constrictor of the pharynx. There is also an 
intimate topographical ^ relation between this inner wall and the inner 
surface of the levator palati (petrostaphylinus, Henle), which muscle, in 
conjunction with the salpingo-pharyngeus, the inner dilator of the tube, 
brings about movements of the cartilage (Fig. 43, c). 

Temor Falati Muscle. — The most important of all the muscles of the 
Eustachian tube is the tensor palati^ (Eig. 43, a). This muscle arises 
by a flat tendon from the posterior edge of the hard palate, in intimate 
connection with the tendon of its fellow of the opposite side, and, gradu- 
ally narrowing into the tendon which passes around the pterygoid hook, 
spreads out again from this point into a fan-shaped muscular layer, the 
free, broad edge of which is inserted into almost the entire length of the 
anterior lip of the cartilage of the Eustachian tube (Fig. 43, a). 

By the contractions of this muscle the anterior wall of the cartilage 
of the tube is pulled outward and downward, and thereby the caliber of 
the canal is widened. 

^ Kiidinger, Ohrtrompete, S. 7. 

^ This muscle sends a few fibres to the posterior cartilaginous wall of the Eu- 
stachian tube near the junction of the cartilage with the bony portion of the tube. 

^ This muscle has received various names : tensor veli ; tensor veli palatini ; dila- 
tator tubse (Eiidinger) ; spheno-salpingo-staphylinus, etc. 



ANATOMY AND PHYSIOLOGY OF THE EUSTACHIAN TUBE. 



51 



According to the investigations of Eiidinger, ^ there is a direct connec- 
tion between the tensor palati (dilatator tubae) and the tensor tympani 
muscle. Xot only do the tendinous fibres, but also the muscular fibres 
of the one pass over into those of the other at the upper part of the Eusta- 
chian tube. This connection is of the greatest importance when con- 
sidering the cause and treatment of certain forms of hardness of hearing 
due to muscular weakness in the tensor veli. 



Fig. 43. 



b 







Diagrammatic section through the Eustachian tube, the muscles and fascise. (On the left side, the 
section is supposed to be a vertical one passing through the tube ; on the right side, it is supposed to 
pass under the floor of the tube.) ( Weber-Liel.) a, tensor veli muscle; b, fascia salpingo-pterygo- 
staphylina ; c, levator palati muscle : d, fascia pharyngea externa, passing into the tubal fascia above ; 
e, buccinator muscle ; g, hard palate ; h, pterygoid hook ; /, fascia pharyngea interna. 



It is now generally conceded, through the labors of Eiidinger and 
others, that there is a small part of the normal Eustachian tube, the so- 
called safety-tube, in its upper part, under the cartilaginous hook, always 
wide enough open to allow a recoil of air to occur from the drum-cavity 
if the drum-head is suddenly driven in, as in explosions, and also to 
permit a slow equalization of pressure in the tympanic cavity, from the 
pharynx, independently of the act of swallowing. But this safety- canal 
is not wide enough to allow constant ventilation of the drum- cavity to go 

^ Op. cit., p. 6. 



62 



DISEASES OF THE EAR. 



on. Therefore, to insure ventilation of the tympanum, the normal tube 
is opened at every act of swallowing. 

The Inner Fterygoid Muscle. — This muscle is considered by Weber- 
Liel as specially belonging to the muscles of the Eustachian tube.^ Ac- 
cording to his observations, some of the upper, shorter, and hinder fibres 
of this muscle are inserted into the fascia of the floor of the tube through- 
out its length, and are then lost in the fibrous covering of the petrous 
bone. Its function is that of a tensor of the fascia of the Eustachian 
tube. 

Fig. 44. 




■^^ ,3* 



Transverse section through the Eustachian tube at its lower end ; slightly magnified. (Sieben- 
mann.) 1, spongy bone of the skull base ; 2, mucous glands and adipose tissue of a tangential section 
through the mucous membrane of Eosenmiiller's fossa ; 3, tubal cartilage ; 4, mucous membrane of 
the lateral portion of the pharynx opened by the above-named section ; 5, retrahens muscle of the 
tube ; 6, levator veli muscle ; 7, mucous glands of the floor of the Eustachian tube ; 8, lumen of the tube ; 
9, mucous membrane of the outer wall of the Eustachian tube ; 10, tensor veli muscle ; 11, mucous 
glands of the inner wall of the Eustachian tube ; 12, internal pterygoid muscle. 

Mucous Membrane of the Eustachian Tube. — The mucous membrane of 
the Eustachian tube is a continuation of that of the pharynx. It is sup- 
plied with ciliated epithelium, the cilia of which move in a direction 
from the tympanic cavity towards the pharynx, thereby favoring the 
passage of fluids from the cavity of the drum and tube into the throat. 

The Eustachian tube is very rich in glands at certain places ; although 
the upper concave portion of the cartilaginous roof of the canal is en- 



1 Progressive Schwerhorigkeit, Berlin, 1870, Ss. 68-71. 



ANATOMY AXD PHYSIOLOGY OF THE EUSTACHIAN TUBE. 53 

tirely free from glands, the sides of the tube, in the pharyngeal portion, 
are richly supplied with acinous mucous glands, emptying into the folds 
of mucous membrane, as shown by Eiidinger. These mucous glands do 
not differ from those of the oesophagus and pharynx. In the upper por- 
tions of the tube, towards the tympanic cavity, all glands become si^arse. 

In addition to the glands just named, Gerlach^has shown that the 
mucous lining of the cartilaginous portion of the tube is richly sui^i^lied 
with follicular glands, which are most numerous at its middle x>art. 
Placed still deeper in the submucous connective tissue are numerous 
acinous glands. The follicles of the tubal mucous membrane are about 
half as large as those of the pharynx, but take in the entire depth of the 
mucous membrane. 

Tonsilla Pharyngea. — According to the investigations of Santorini and 
Luschka, it is shown that the lining structures of the roof, and to a great 
extent the hinder wall of the nasal part of the pharynx, are composed of 
a tissue so strikingly like the substance of the tonsils that it has been 
named the "pharyngeal tonsil." 

Luschka states that this spongy tonsillar substance, of a maximum 
thickness of seven millimetres, which he has never failed to find, extends 
from the posterior boundary- of the roof of the nasal cavity to the edge 
of the foramen magnum of the occii)ital bone, where it assumes a more 
or less uneven surface, or, breaking u^d into separate sebaceous glands, is 
gradually lost in the posterior wall of the pharynx. The same kind of 
structure forms the chief constituent of the recessus pharyngeus, and 
extends in a thinner layer over the ridge of the pharyngeal mouth of the 
Eustachian tube. 

Differences in Size and Slmpe of Mouth of Eustachian Tube. — Urbant- 
schitsch- has described great variations in the shape and size of the 
pharyngeal mouth of the Eustachian tube. These variations occur not 
only in those of the same age, but also in the same individual. 

Blood-vessels and Xerves of the Eustachian Tube. — The arteries supplying 
the Eustachian tube are the pharyngeal from the external carotid, the 
middle meningeal branch of the internal maxillary, and various small 
branches of the internal carotid. 

The nerves are distributed as follows. The tensor palati, or the dilata- 
tor tubie muscle, is suj^iDlied by a branch from the otic ganglion, and also 
by a motor branch from the internal pterygoid nerve, a muscular branch 
of the smaller division of the inferior maxillary nerve. The levator 
palati muscle is suj^plied by the facial nerve through its connection with 
the Vidian and petrosal nerves, as well as by a branch from the vagus. 



^ Zur Morphologie der Tuba Eustachii. Sitzungsberichte d. Erianger Physicalisch- 
Med. Soc. Abstract by von Troeltsch, A. f. O., 1875, Bd. x. S. 53. 

^ Anatomische Bemerkungen liber die Gestalt und Lage des Ostium pharyngeum 
tubc^ beim Menschen. A. f. O., 1875, Bd. x. Ss. 1-7. 



54 



DISEASES OF THE EAR. 



The inner dilator of the tube, the salpingo-pharyngeus, is supplied by 
the glossopharyngeal nerve. The inner pterygoid muscle is supplied by 
the inferior maxillary nerve. The mucous membrane of the tube is sup- 
plied by branches of the glossopharyngeal nerve, which also supplies the 
mucous membrane of the tympanic cavity. 

The Mastoid Fortion of the Temporal Bone and its Cells. — The mastoid 
portion is that highly important part of the middle ear situate behind 
and partly below the cavity of the tympanum. It corresponds to the 
protuberance behind the auricle. This hollow portion is developed 
partly from the squamous portion, but chiefly from the petrous part of 
the temporal bone. As is well known, the temporal bone is formed from 
three distinct pieces, the squama, the annulus tympanicus, and the 

petrous pyramid. The squama is divided into 
Fig. 45. two i)arts, — viz. , the vertical and the horizontal 

portions. The horizontal portion is subdivided 
into an inner and an outer lamella, the latter 
of which forms part of the air-cavities of the 
mastoid portion. This portion of the temporal 
bone has a distinct existence by the fifth foetal 
month. The mastoid portion is really a con- 
tinuation of the petrous part of the temporal 
bone backward and downward. 

The upper surface of the mastoid portion 
unites with the postero-external edge of the 
roof of the tympanum. This is marked by a 
furrow until immediately after birth, when it 
usually becomes invisible. 

In a child a few months old the outer sur- 
face shows a deficiency at its upper and ante- 
rior edge, — the so-called mastoid- squamous 
fissure. Sometimes, at this early age, the fis- 
sure is not at all marked, its place being rep- 
resented by a series of irregular openings varying from two to three 
millimetres in diameter, as though union between the squama and the 
outer mastoid wall was already far advanced. 

The inner surface is quite concave, and over it runs a furrow, which 
at last is fully developed into the sigmoid sinus. 

The mastoid foramina are found near that j)oint where the upper and 
under edges of the mastoid portion meet. In some cases the foramina 
are not complete until the occipital bone joins the mastoid edges. These 
openings are for the passage of arteries to the dura mater, and for small 
veins which connect the transverse or lateral sinus with the veins of the 
scalp. 

Mastoid Cells. — Within the mastoid portion are found the mastoid cells. 
These are a series of bony air-chambers of variable size, communicating 




Mastoid cells, left side, viewed 
from behind. (C. J. Blake.) 



ANATOMY AND PHYSIOLOGY OF THE EUSTACHIAN TUBE. 



55 



Fig. 4G. 



1-- 

2--- 

3--- 

4__ 
5- — 
6 -- 
7. — 
8- — 




Tvith one another by means of foramina in their thin walls. They com- 
municate with the tympanic cavity by means of the mastoid antrum and 
aditus, and are lined by a continuation of the same mucous membrane 
lining the Eustachian tube and tympanic cavity. The number and devel- 
opment of these cells vary, not only in different individuals, but in the 
same individual, on the two sides. It is of the highest importance to 
understand their general distribution in the adult bone, in order to diag- 
nosticate and treat inflammatory processes arising there, or which have 
spread to that part from the tympanic cavity. 

In the mastoid portion of the child it is found that the septum di- 
viding the mastoid cavity from the sigmoid sinus is very thick, and hence 
inflammation is not likely to pass 
from the former to the latter, as it 
is in adults, in whom this sei)tum is 
always thin. Hence, in very young 
children, meningitis very rarely, if 
ever, occurs from inflammation of 
the mastoid cavity, from which in- 
flammation tends to pass outward 
rather than inward, not only be- 
cause the dividing septum between 
it and the sigmoid sinus is thick, 
but because, as already stated, the 
outer wall of the mastoid portion is 
imx^erfect in early childhood. This 
is the reverse of what we find in the 
adult, so that in the latter every- 
thing favors a passage of disease of 
the mastoid cells inward towards 
the brain, while in the child the con- 
ditions are in favor of a passage 
outward of disease in this region. 

The lower i)ointed part of the mastoid portion is known as the mastoid 
process (Fig. 41, 10 ; Fig. 17, 18) ; to it the sterno-cleido -mastoid muscle 
is attached. The development of the mastoid process is greater in the 
strong and muscular, while it is less developed in the weak and in chil- 
dren. The mastoid portion is also subject to differences in development 







^^"- 



Auditory apparatus, left side, viewed from 
above, after removal of the tegmen tympani and 
upper half of the labyrinth ; natural size, from 
photograph. 1, internal auditory canal ; 2, audi- 
tory nerve ; 3, modiolus of cochlea ; 4, vestibule 
and horizontal semicircular canal ; 5, membrana 
tympani, inner surface ; 6, annulus tympanicus ; 
7, malleo-incudal joint ; 8, aditus ad antrum ; 9, 
antrum ; 10, mastoid cells ; 11, middle cranial 
fossa, back part. 



in different races, being small and solid 



m 



while in Monsrolians 



it is found much more highly developed than in Caucasians, as shown by 
Welker. 

In the first year after birth the mastoid cavity loses its pyramidal shape 
by assuming a more ovoid form, and the mastoid cells are formed gradu- 
ally. Those which are included in the upper and outer portion of the 
mastoid where it joins the squama are the most highly developed at this 
time, and lined with mucous membrane, while the mastoid process as yet 



56 



DISEASES OF THE EAR. 



contains no air-cells. From this time on the external differences of this 
part of the temporal bone are much less than the differences in devel- 
opment of the air-cells within, for the latter are subject to the greatest 
variations in number and distribution, as can readily be seen in the skulls 
of adults. 

The so-called mastoid ant^^um is really part of the tympanic cavity, 
and is of a triangular shape (Fig. 34, h). Its position is somewhat 
abovC; in front of, and farther inward than the rest of the mastoid 
cells. Its walls, with the exception of part of its outer wall, are formed 
by the petrous part of the temporal bone, and communicate by numer- 
ous perforations with the mastoid cells, by which it is surrounded on 



Fig. 47. 




1615U 13 121110 



Cast of the left middle ear ; view of inner surface of tlie cast shown in Fig. 41. (Siebenmann.) 1, 
outer upper horizontal cell of the squama ; 2, anterior upper horizontal cell of the squama ; 3, tegmen 
antri ; 4, superior malleo-incudal fold ; 5, posterior upper horizontal cell of the squama ; 6, facial 
nerve ; 7, oval Avindow with the crura of the stapes ; 8, wall of the fauces ; 9, internal carotid, with its 
sinus in white ; 10, tympanic cell ; 11, carotico-tympanic canals ; 12, vascular canals between the jugu- 
lar bulb and the drum-cavity ; 13, aquseductus cochleae ; 14, round window ; 15, jugular bulb ; 16, pos- 
terior tympanic sinus ; 17, small inner mastoid cells ; 18, large inner cell of the mastoid process placed 
directly under the transverse sinus. 

all sides excepting in front and on the inner side. Anteriorly it has 
a wide opening into the tympanic cavity, the aditus (Fig. 46, 8, 9), and 
on its inner side it is bounded by that part of the petrous bone cover- 
ing in the horizontal semicircular canal. The air- containing cavities 
fill the entire mastoid portion of the temporal bone, and in most cases 
they spread downward and outward to the very point of the mastoid 
process. 

Limits of the Mastoid Cells. —The mastoid cells extend as far backward 
as the emissarium mastoideum, where they are in close contact with the 
outer side of the groove for the sigmoid sinus, and they are found as far 
forward as the external auditory canal. Mastoid cells are also found 
continuous with those which reach as far forward and upward as the 
petrosquamous suture, above the point where the outer table of the 



ANATOMY AND PHYSIOLOGY OF THE EUSTACHIAN TUBE. 57 

mastoid portion is nearest the inner table, — that is, the outer wall of the 
sigmoid groove (Fig. 41, 5-10, and Fig. 47, 1-3, 5-18). 

The lowest limit of the mastoid cells is the tij) of the mastoid process. 
Those cells which are developed from the petrous part of the bone are 
the largest ; those which arise from the squama and lie over the external 
auditory canal are the smallest. 

Conjoint FhysioJogy of the Eustachian Tube, Tympanic Cavity, and Mas- 
toid Cells. — According to the carefully conducted experiments of Mach 
and Kessel ^ on the functions of the tympanic cavity and the Eustachian 
tube, it is shown that sound-waves will produce the greatest effect when, 
in the middle ear, the following three conditions are maintained : 

1. The Eustachian tube must, as a rule, remain closed. 

2. It must, however, be opened occasionally for purposes of venti- 
lation. 

3. The tympanum should be in connection with large, irregular 
cavities. 

* Die Function der Trommelhohle und der Tuba Eustachii. Sitzungsberichte der 
k. k. Academie d. Wissensch., 1872. See also Archiv f. Ohrenh., N. F., Bd. ii, Ss. 
116-121. 



CHAPTEE YL 

THE ANATOMY AND PHYSIOLOGY OF THE INTEENAL EAE AND 

AUDITORY NERVE. 

EMBRYOLOGY OF THE LABYRINTH, OR INTERNAL EAR. 

The membranous labyrinth of tbe internal ear is the oldest part of 
the auditory apparatus. It originates from a thick, circular patch of 
ectoderm on the dorso-lateral surface of the head region of the embryo 
near the dorsal termination of the first outer visceral furrow. (Heissler.) 
This thickened area sinks below the surface, forming the auditory pit, 
and is already present in the third week of embryonal life. This pit be- 
comes deeper, and its edges come together and unite, thus forming the 
otic vesicle, or otocyst. This epithelial sac, from 0.3 to 0.4 millimetre in 
diameter, gradually recedes from the surface of the ectoderm, and sinks 
into the mesodermic tissue surrounding the brain vesicles until it reaches 
the region of the after-brain, and thus comes into close relation with the 
acoustico- facial ganglion. (Siebenmann. ) By the end of the first month 
of pregnancy a dorsal projection shows itself on the otic vesicle, which 
becomes the recessus vestibuli, finally lengthening into the ductus endo- 
lymphaticus. The dilated end of the latter becomes the saccus endolym- 
phaticus, and in the adult occupies the aquseductus vestibuli of the tem- 
poral bone. By a bulging of the anterior or ventral extremity of the 
otic vesicle the evaginated, tapering cochlear duct or the scala media of the 
future cochlea is formed. The otic vesicle soon becomes constricted, so 
as to indicate its future division into an upper larger and a lower smaller 
sac. During the fifth and sixth weeks of pregnancy various processes 
are thrown out at that part of the vesicle which is to become the utncidus. 
Thus the membranous semicircular canals are formed. The smaller part 
of the otic vesicle resulting from the aforesaid constrictions becomes the 
saccule, that part from which the cochlear duct is evaginated. ''The line 
of division between the utriculus and sacculus coincides with the middle 
of the orifice of the ductus endolymphaticus, the proximal end of which 
participates in the division. Thus the ductus endolymi^haticus becomes 
a Y-shaped tube, and affords the only bond of connection between the 
saccule and the utricle.'^ (Heissler.) 

The utricle, the saccule, the semicircular canals, and the cochlear 
duct being products of the ectodermic otic vesicle, represent simply the 
epithelial linings of these cavities. Heissler ^ speaks of this lining of the 
membranous labyrinth as a mucous membrane. The fibrous layer of the 

1 Text-Book of Embryology, p. 325. 
58 



ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. 59 

membranous labyrinth originates from the enveloping mesodermic tissue. 
From the cells of the otic vesicle lining the internal walls of the several 
sacs and canals of the membranous labyrinth originate the specialized 
neuro- epithelium. From the latter are formed Corti's organ in the 
cochlea, the macidce acusticw of the saccule and utricle, and the cristce 
acusticce of the ampullae of the semicircular canals. 

By the end of the sixth month the labyrinth is entirely enclosed in 
bone. The development of the bony labyrinth of the internal ear, as 
well as the connective-tissue parts of the membranous labyrinth, is 
effected solely by the differentiation of the mesodermic tissue surrounding 
the epithelial structures above considered. (Heissler.) B}^ this differ- 
entiation there is first produced a cartilaginous ear-capsule. This is larger 
than the enclosed epithelial labyrinth, and separated from the latter by 
embryonal connective tissue. Before ossification occurs this interme- 
diate embryonal connective tissue differentiates into three layers. The 
innermost adheres to the epithelial labyrinth, and, becoming transformed 
into fibrous tissue, becomes the connective-tissue component of the mem- 
branous semicircular canals. The outer layer undergoes condensation, and 
becomes the fibro-vascular perichondrium, or internal periosteum of the 
bony semicil'cular canals. The middle laj^er becomes softer, fluid-filled 
cavities appear in its meshes, and by their coalescence a space is formed 
around the membranous semicircular canals filled with fluid, the j)eri- 
lymph. This space is bridged across at certain points by connective-tissue 
trabecuhe conveying blood-vessels to the membranous semicircular canals. 
The vestibule is formed in the same way from the mesoderm, and its mem- 
branous sacculi acquire their connective-tissue elements in the same 
way. The bony cochlea is developed upon the same principles, but there 
are important modifications of form caused by the fact that after the chon- 
drification of the capsule begins, and encloses the cochlear duct, the fur- 
ther growth takes place in a spiral direction around an axis in which lies 
the cochlear nerve. This connective tissue is at last converted into the 
modiolus, from which the cochlear nerve sends forth branches upon the 
lamina spiralis and membrana spiralis, and thence to the organ of Corti. 
The cochlear duct is surrounded by undifferentiated mesodermic tissue. 
The lamina spiralis divides this into two parts, which finally become the 
scala vestibuli and the scala tympani. The innermost layer of this soft 
embryonal tissue, in close relation with the epithelial cochlear duct, be- 
comes fibrous tissue and connective tissue, and forms the fibrous layer of 
the developed cochlear duct, — i.e., on the scala tym^Dani side of the duct 
it becomes the connective-tissue layer of the membrana basilaris, while on 
the side towards the scala vestibuli it forms the fibrous layer of Eeissner^s 
membrane. The peripheral layer of embryonal tissue becomes the future 
periosteum of the inner surface of the bony cochlear wall. From retro- 
gression of the tissue intervening between these two layers the two spaces 
known as the scala vestibuli and the scala tympani are formed, containing 




60 DISEASES OF THE EAR. 

the perilymph. This perilymphatic space communicates with the vesti- 
bule, and places the vestibular and tympanic scalae of the cochlea in the 
perilymphatic system of the labyrinth, while the cochlear duct, or the 
scala media of the cochlea, contains endolymph, like the sacculi of the 
vestibule and the membranous semicircular canals, and is therefore part 
of the endolymphatic system of the labyrinth. 

ANATOMY OF THE LABYRINTH AND AUDITORY NERVE. 

The internal ear, sometimes called the labyrinth, is composed of a 
bony portion or case, and a membranous portion contained in the latter. 

The bony as well as the membranous portion 
of the internal ear consists of the vestibule, the 
central portion, with which the cochlea is con- 
nected in front, and the semicircular canals^ 
behind. 

The Vestibule. — The vestibule is a small 
cavity situate just beyond the inner wall of the 
tympanum. This wall is common to both cavi- 
ties, and in it is the oval window, into which 
^ f 1 .^ '^ ^ ,,, fits the foot-plate of the small stirrup bone 

External view of a cast of the ^ ^ 

left labyrinth. (Henie.) /, fe- (Fig. 48, a). A sectiou of the vcstibule parallel 
nestra cochlea, or round window; ^^ ^^g tympanic wall is rouud Or elliptic, but a 

a, fenestra vestibuli, or oval win- ^ ^ x / 

dew; 6, ampulla of superior semi- SCCtlOU at right angles tO thlS, and running par- 
circular canal ; e, ampulla of pos- ^llel to the floor of the tympanum, is in general 

terior semicircular canal ;d, _ , ,, .,^,.,.-,. ., 

common shaft of union of these of a pear shapc, the poiut of which IS directed 
two canals ;c, ampulla of the hori- forward. This, of coursc, indicates that there 

zontal semicircular canal \ g, ' i j. j j.i j. n j.^ jy 

tractus spiralis foraminosus. !» ^ general tendency on the part of the four 

walls of the vestibule to unite anteriorly near 
the cochlea. This convergence of the vestibular walls is seen in Plate I. 
The average distance of the outer from the inner wall of the vestibule is 
from three to four millimetres 5 its long diameter, running between its^ 
anterior and posterior limits, is about five millimetres, as given by Henle. 

The Ampullar Mouths of the Semicircular Canals. — On the upper wall of 
the vestibule, just above the recessus ellipticus, is the ampullar opening 
of the superior semicircular canal ; in the angle between the posterior 
and inner walls, near the inner opening of the aquseductus vestibuli, is 
found the ampullar opening of the common end of the superior and pos- 
terior semicircular canals. At about the same height in the centre of the 
posterior wall is the posterior opening of the horizontal semicircular 
canal. The lower opening of the posterior semicircular canal is in the 
angle formed by the union of the posterior, the inferior, and the inner 
walls of the vestibule. The anterior ampullar mouth of the horizontal 
semicircular canal is in the outer wall between the oval window and the 
ampulla of the superior semicircular canal (Fig. 48, c). 

Maculce Cribrosce. — These are groups, of fine microscopic openings 



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AX ATOMY AXD PHYSIOLOGY OF THE INTERXAL EAR. 61 

through which the nerves enter the vestibule. The superior group is 
found at the upper spinous termination of the crista vestibuli, a second 
group is in the recessus sphaericus, and a third is situate at the ami)ullar 
opening of the posterior semicircular canal. Through the superior crib- 
riform spot nervous filaments pass to the utriculus and to the ampullae 
of the superior and the horizontal semicircular canals, through the 
middle cribriform spot nerves pass to the sacculus, and through the 
lower spot the ampulla of the posterior semicircular canal is supplied 
(Plate I., 9 and 14). 

Eeichert has described a fourth cribriform spot, in the upper part of 
the recessus cochlearis, near the origin of the lamina spiralis. This gives 
admission to a filament from the smaller branch of the cochlear nerve, 
which is distributed to the septum between the sacculi in the vestibule.^ 

Tlw Cocldea. — The bony cochlea may be described very briefly as an 
osseous canal twisted spirally two and a half times about a bony pillar. 
This shape closely resembles that of a snail-shell, and has suggested the 
name of the cochlea. The bony cochlea may be divided into tlie spiral 
canal, modiolus, and the lamina s^Diralis ossea, which, projecting from the 
modiolus into the caliber of the canal of the cochlea, terminates above 
at the helicotrema in what is named the hamulus. 

The Canal of tJie Cochlea. — The cochlear canal starts at the extreme 
outer and lower corner of the vestibule and, winding outward and forward, 
makes in its first half-turn the promontory of 
the inner wall of the tympanum. Fig. 49. 

Each turn of the cochlea is shorter than the 
previous one, and rising above and beyond it 
outwardl}^ forms the peculiar resemblance indi- 
cated b}' its name. The height of the cochlea 
is equal to the diameter of its base, and measures 
about four or five millimetres. The entire length 
of the cochlear canal is from twenty-eight to 
thirty millimetres. t 

The modiolus (Fig. 49, b), which mav be re- ^ .. " .^ ^' ^ . 

^ ° ' ^^ *- Section through the osseous 

garded as representing the axis of the cochlea, is capsule and the modiolus of the 
nearly in the axis of the porus acusticus internus cochlea, with the lamina spiralis 

*; . Ill T n ossea. (Politzer.) a, internal 

and about at right angles to the long diameter of auditory canai ; b, modiolus. 
the pyramid of the i)etrous bone. The point of 

the cochlea is directed outward, forward, and downward. The latter part 
of the cochlea, the cupola, is separated by a thin plate of bone from the 
canal of the tensor tympani muscle, while in front the coils are very close 
to the carotid canal. The diameter of the canal of the cochlea is about 
one millimetre at its widest part ; from the beginning of the last half- 
turn it becomes much smaller. A transverse section of the cochlear 

^ Henle, op. cit., p, 760. 




62 DISEASES OF THE EAR. 

canal varies in shape, being sometimes elliptical and at other times semi- 
circular. Its more common shape is that of a segment of a circle, the point 
of which is directed toT^^ards the axis of the cochlea. The thickness of 
the dividing wall between the turns of the cochlea is three-tenths of a 
millimetre at the lower turn and three-hundredths of a millimetre at the 
upper part of the canal. 

The Modiolus and Lamina Spiralis Ossea. — The general shape of the mo- 
diolus is pyramidal. At its base the diameter is two millimetres, at the apex 
five-tenths of a millimetre, and its height is two and a half millimetres. 

The modiolus is not only the bony axis about which the cochlear canal 
is twisted, but it is traversed by numerous canals for the transmission of 
blood-vessels and the branches ot the cochlear nerve, which are finally 
distributed like fringe on a bony shelf running spirally around the modi- 
olus and projecting into the canal of the cochlea (Plate II.). This bony 
shelf is the lamina spiralis ossea (Plate I., 37). 

TJie Scalm. — The lamina spiralis ossea divides the canal of the cochlea 
into its scalse. The upper one of these is the scala vestibuli, beginning 
at the vestibule and continuing to the helicotrema ; the lower one, the 
scala tympani, may be said to begin at the helicotrema and end at the 
round window (Fig. 50, sc v and sc t). 

The general relation of the spiral bony lamina to the scalse, and the 
relation of the latter to each other, will perhaps be better understood if 
the reader imagines himself starting from the vestibule along the upper 
surface of the bony partition between the scalse, and continuing until he 
reaches, at the helicotrema, the sharp hook-like end of the bony lamina. 
At this point he must imagine that what has been the floor of the scala 
vestibuli now becomes the upper surface or root of the scala tympani. 
If the scala tympani be traversed, in imagination, two and a half turns 
will reach the membrane of the fenestra rotunda. 

The lamina spiralis ossea forms only part of the division between the 
scalse 5 as it does not pass as a bony septum from the modiolus to the 
opposite wall of the canal, the separation of the two scalse from each 
other is not complete until the soft parts are added to the osseous struc- 
tures (Fig. 50, 6). The lamina spiralis is thicker at its lower end than 
at the top of the modiolus. At the former point it may amount to three- 
tenths of a millimetre, but at the upper part to only fifteen-hundredths of 
a millimetre. The width of the lamina spiralis is one and two-tenths milli- 
metres at the lowest part and five-tenths of a millimetre at the upper part. 

The Semicircular Canals. — To the posterior part of the vestibule are 
attached the three semicircular canals. These are named, accoi'ding to 
their positions and planes, the superior, the posterior, and the horizontal 
semicircular canal (Fig. 48). 

Although there are three distinct canals, there are but five openings 
from them into the vestibule. This is due to the fact that two of the 
canals, the superior and the posterior, are joined to a common shaft just 




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ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. 63 

before they reach the vestibule (Fig. 48, d^ and Plate I., 17, 21, and 22). 
The position of these ox^eiiings on the wall of the vestibule has been de- 
scribed already. At one end, each of the canals has a dilated portion, its 
ampullar enlargement. These enlargements contain soft parts of similar 
name and shape, the ampullse of the membranous semicircular canals 
(Plate I., 15, 18, and 24). 

Dimensions of the Semicircular Ccuuds. — The length of the posterior 
semicircular canal is the greatest of the three, amounting to twenty-two 
millimetres. The length of the superior canal is twenty millimetres, and 
that of the horizontal canal is only fifteen millimetres, as shown by Huschke 
and Henle. The common shaft of the superior and posterior canals is 
from two to three millimetres long. 

A transverse section of these canals is elliptical. The long diameter 
is to the shorter as 2 : 3 or 3 : 4. The longer measures, in man, from one 
and three-tenths to one and seven-tenths millimetres. (Henle.) 

Ampullar Enlargement. — The shape of the ampullse is that of an ellip- 
soid. The ampulla of the superior and of the i)Osterior canal is sharply 
defined from the rest of the canal, as well as from the vestibule, by a 
ridge, but the horizontal semicircular canal glides gradually into its 
ampullar end. The height of the ampulla, in the centre, is about two 
and one-half millimetres, not quite as great as the longer diameter of its 
caliber. 

The Planes of the Semicircular Canals. — The superior and posterior 
canals are in vertical i^lanes at right angles to each other. The hori- 
zontal semicircular canal, as its name shows, is in a plane at right angles 
to that of each of the others. The top of the superior canal points upward, 
making thus a visible ridge on the anterior surface of the petrous bone. 
The top of the i)osterior canal i)oiuts directly backward, as does that of 
the horizontal semicircular canal (Fig. 48). 

Soft Farts of the Cochlea. — If a transverse section of the canal of the 
cochlea be examined under the microscope, the manner in which the 
canal is subdivided into its scalae will be seen. This division is first indi- 
cated by the j)rojection of the lamina spiralis ossea into the caliber of the 
canal. The free end of this bony shell will, therefore, form a good point 
for beginning the consideration of the topographical arrangement of the 
different parts of the cochlea (Plate II.). 

Soft Parts of the Lamiim Spiralis Ossea. — Upon the upper surface of the 
lamina spiralis ossea rests the vestibular lamella, and upon the under 
surface is placed the tj^mpanal lamella of the lamina spiralis ossea. 
Through the bone lying between these lamellse runs the nerve on the way 
to its termination at the organ of Corti and the ciliated cells, a descrip- 
tion of which will be given later. 

The tympanal lamella is continued in the same plane, directly across 
from the under edge of the lamina si)iralis ossea to the opposite wall of the 
cochlear canal. Here it is joined to the latter at the thickest point of a 



64 



DISEASES OF THE EAR. 



cushion of connective tissue called the ligamentum triangulare (Fig. 50, 
Z). The division of one scala from the other is novr complete, by the for- 
mation of the memhy^na basilaris (Fig. 50, b). This membrane does not 
seem to be very elastic, according to recent observations of Waldeyer. 



Fig. 50. 




Section through the lower turn of the cochlea of a new-born infant. (Politzer. ) sc v, scala vestibuli ; 
set, scala tj-mpanica ; k, lamina spiralis ossea ; b, memhrana basilaris ; I, ligamentum triangulare; E, 
membrana Reissneri ; cc, scala media ; o, Corti's organ ; m, Corti's membrane ; n, fasciculus of the 
ramus cochleBe ; gs, ganglion spirale. 



The upper or vestibular lamella of the lamina spiralis ossea is the thicker 
of the two. About half-way between its origin and the point of the si^iral 
bony lamina the vestibular lamina is thickest, from which point it seems 
to taper to the edge of the bony shelf on which it lies. 

At this thick part there rises a delicate membrane, the membrane of 
Eeissner, which springs across the scala vestibuli, and is fastened at a 
point on the opposite wall of the cochlea about forty degrees above its 
starting-point. This is a most important membrane, since it forms the 
upper or vestibular boundary of the ductus cochlear is (Fig. 50, E). 

The membrane of Eeissner is said to consist of a thin conective-tissue 
basement lamella, rich in vessels. On its vestibular surface large-celled, 
serous epithelium is found, and on its tympanal surface a single layer of 
regularly arranged, cubic epithelial cells. 

It will now be seen that the cochlear canal is really subdivided into 
three canals, — the scalse already named and the ductus cochlearis, or 
scala media, which is formed at the expense of part of the scala vestibuli 
(Fig. 50, cc). The ductus cochlearis may, therefore, be said to lie upon 
the membrana basilaris above the grand division -line of the scalse, and 
should, indeed, be imagined as slipped into a triangular canal lying be- 
tween the scalse at their outer edges. The scalse are lined with perios- 
teum, covered with large, flat epithelium. They are filled with peri- 



ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. 65 

Ij'mijli, and are in communication with each other only at the helicotrema 
in the cuj^ola of the cochlea. 

The ductus cochlearis is not in communication with them at any 
point 5 it begins and terminates in so-called blind ends. The scala tym- 
pani ends at the membrane of the round window, but the scala vestibuli 
is in free communication with the vestibule. 

Crista S2)iraUs. — From the point where the membrane of Eeissner is 
attached to the vestibular lamella of the lamina spiralis ossea there 
extends a crest or ridge of connective tissue and developed epithelium 
called the crista spiralis, the serrated edge of which is called by some 
anatomists ' * aural teeth. ' ' ^ From this free peculiar edge rises the mem- 
brana tectoria, or Corti's membrane, which extends as far as the be- 
ginning of the organ of Corti (Fig. 50, m). 

The space between the crista spiralis and the point of junction of 
the lamina spiralis ossea and the membrana basilaris is called the sulcus 
spiralis internus (Fig. 51, a). 

Corti's organ extends from the junction of the membrana basilaris and 
lamina spiralis ossea to a middle point on the former membrane. From 
this point the epithelial lining of the ductus cochlearis pursues a less 
complicated course outward and upward over the wall of the duct (Fig. 

50, o). 

Hahenula Perforata and the Zonce. — The habenula perforata is situate 
at the extreme thin edge of the osseous spiral lamina, and gives exit to 
the nerve-branches. The zona denticidata extends from the crista spiralis 
to the outer end of Corti's organ ; the zona arcuata, from the inner to 
the outer ciliated cells ; and the zona pectinata extends from the outer 
boundaiy of the organ of Corti to the spiral ligament of Henle (Fig. 

51, n). These names are descriptive of the ai^pearance of the region 
extending from the crista spiralis to the ligamentum spirale, when viewed 
from above. 

The bony portion of the cochlear capsule is divided into a compact 
inner layer, a tabula vitrea, and the more porous modiolus and lamina 
spiralis. In the latter is found the canalis ganglionaris, in which lies the 
spiral ganglion of the auditor}^ nerve (Fig. 50, gs\ The inner surface 
of the periosteum of the canal is covered with a layer of simple, large, 
flat, nucleated cells, similar to those found on the surface of serous mem- 
branes. 

Ductus Cochlearis. — From the foregoing description of the three 
divisions of the cochlear canal it must have been seen akeady that the 
most important of these is the ductus cochlearis (Fig. 50, cc). It is, 
indeed, from the epithelial lining of this important capsule that the 
highly organized contents of the cochlea are developed, so as to be the 
recipients of the terminal filaments of the auditory nerve, after it passes 

^ Gehorzahne of Buschke. 



66 



DISEASES OF THE EAR. 



the habenula perforata and reaches the cavity of the ductus cochlearis 
(Fig. 51, u and &). 

The most important of these structures is the organ of Corti. 

The Marquis of Corti ^ was the first to describe this apparatus, and it 
has from that time justly borne his name. Kolliker and Deiters subse- 
quently enriched the knowledge possessed respecting this important 
part of the internal ear. 

The best treatise on the structure of the cochlea and the distribution 
in it of the auditory nerve has been written by Professor Waldeyer.^ 
Gottstein, his colaborer, has added the most important facts concerning 
the ultimate distribution of the auditory nerve to the outer ciliated cells. 

Fig. 51. 




Transverse section of the organ of Corti ; magnified eight hundred diameters. (Waldeyer.) y, o, 
homogeneous layer of the membrana basilaris ; n, vestibular layer of the same, corresponding to the 
radii of the zona pectinata ; p, tj-mpanal layer with nuclei, granular cell-protoplasm, and transversely 
cut connective-tissue fibrillse ; y, labium tympanicum of the crista spiralis ; w, continuation of the 
tympanal periosteum of the lamina spiralis ossea ; u, thickened origin of the membrana basilaris imme- 
diately beyond the point of entrance of the auditory nerve b ; r, vas spirale ; v, blood-vessels ; x, nerve 
fasciculus ; a, epithelium of the sulcus spiralis internus ; d, inner ciliated cell ; c, its basilar process : 
about the latter and above the point of entrance of the nerve are some cells and fine granular matter 
in which the nerve-fibrils are distributed (granular layer) ; e, inner part of the capital of the inner pillar 
and the point where the cilia of the inner ciliated cells are situated ;/, point of junction of the arches ; 
the body of the outer pillar is severed in the middle ; behind it appear the body and base of the next 
pillar at q ; t, base with part of the granular protoplasm of the inner pillar ; g, i, j, three outer ciliated 
cells ; TO, basilar part of two other ciliated cells ; I, Hensen's supporting cell •,f-k, lamina reticularis ; s, 
nerve-fibril distributed to the first ciliated cell, g, and traceable through the arch as far as the point of 
entrance of the auditory nerve at b. 

Organ of Corti. — The position on the membrana basilaris occupied by 
the organ of Corti has already been pointed out (Fig. 50, o). An idea 
of the general structure and appearance of this wonderful central portion 
of the ductus cochlearis can be gained by consulting Fig. 51. 

Fillars and Arches of Corti. — Upon the upper or vestibular surface of 



^ Von Siebold and KdUiker's Zeitschr, f. Zoologie, 1851. 
2 Strieker's Manual of Physiology. 



AXATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. 67 

the membrana basilaris are two sets of pillars, an inner and an outer row, 
uniting above and forming a series of arches (Fig. 51, s). The pillars, 
like the arches, are named after Corti. They are about three thousand in 
number, according to Kolliker. A head, head-plate, foot, and body are 
parts into which anatomists have divided the pillars. At the junction 
of the pillars, the head of the outer is fitted into a depression between the 
head and head-plate of the inner pillar (Fig. 51, /). 

The tunnel thus formed by the arches of Corti is triangular in outline, 
the longest side of which corresponds to the membrana basilaris. This 
tunnel extends the entire length of the lamina spiralis almost to the end 
of the hamulus, as described by Waldeyer. As a rule, the height and 
width of the arches increase towards the hamulus, as shown by Hensen. 

Inner Ciliated Cells. — On the inner side of the arched roof thus formed 
is found the single row of inner ciliated cells (Fig. 51, e). The latter 
are finally lost at their lower end, in what is termed the ^'granular layer." 
Their upper ciliated ends are received into corresponding head-plates of 
the inner pillars. Tlieir cilia, arranged in dense tufts, are exceedingly 
stiff and strong. 

Outer Ciliated Cells. — The outer ciliated cells are arranged in five par- 
allel rows beyond the row of the external pillars, and underneath the 
membrana reticularis. 

Membrana Reticularis — The membrana reticularis, as its name indi- 
cates, is a net-like structure. It is one of the most comi)licated parts 
of Corti' s organ, extending from the junction of the pillars to the so- 
called support-cells at the outermost row of the ciliated cells. Into the 
meshes of this delicate reticulate membrane fit the tufts of cilia of all 
the outer ciliated cells. A profile view of this arrangement can be seen 
in Fig. 51, f-l. 

Surface of the Memhrana Beticularis. — Viewed from above, the mem- 
brana reticularis presents not only a very beautiful, but an equally com- 
plex appearance. It will be seen that the ciliated cells occupy alternate 
openings in the mesh of the reticulate membrane in both directions, thus 
giving a checker-board arrangement to the ciliated tufts and the inter- 
mediate spaces when viewed from above (Fig. 51, i and J). 

The constituent elements of Corti' s organ have now been described as 
briefly and in as condensed a way as possible. Of this Avonderful organ, 
AValdeyer says that, if there be left out of this consideration the peculiar- 
ities of the inner ciliated cells, the apparently complicated structure of 
Corti' s organ reveals really a simple plan. Several rows of cylinder cells 
(double cells) are arranged in regular order on a broad zone of the spiral 
shelf. These rows are parallel to one another, and are held firmly in their 
position between two membranous boundaries, the membrana reticularis 
and the membrana basilaris. Two sets of these cylinder cells (the pillar 
cells) become developed for the purpose of forming a firm arch of support 
for the whole. Specially worthy of note is the fixation of the outer cili- 



68 DISEASES OF THE EAR. 

ated cells, wMch, by means of processes and their head-piece, are im- 
movably held between the membrana reticularis and the basilar mem- 
brane. These cells, together with the pillars of Corti, exist only in man 
and other mammals. To this apparatus— i. e. , to its peculiar ciliated cells 
— the terminal filaments of the auditory nerve are directly sent (Fig. 
51, s). ^ 

Auditory Nerve ; Origin and Distribution. — According to the investiga- 
tions of Stieda in 1868, the auditory nerve springs by two roots from the 
medulla oblongata. The fibres of one of these are more delicate than 
those of the other. It originates from a ganglionic nucleus on the floor 
of the fourth ventricle. The second root, which is said by Stieda to con- 
tain larger axis- cylinders than any other nerve, springs from a special 
large- celled ganglionic nucleus in the crus cerebelli. This root acquires, 
soon after it leaves the medulla, a small ganglion, like one of the posterior 
roots of the spinal cord. Both roots soon unite into a common trunk, but 
divide again in the porus acusticus internus into two branches, the vestib- 
ular and cochlear branches. 

Vestibular and Cochlear Branches of the Auditory Nerve. — The first con- 
tains a small ganglion, intumescentia gangliformis Scarpse, and divides 
into the ampullar branches and those for the utriculus and the sacculus. 

The cochlear branch, which is by far the larger of the two, gives off 
a small fasciculus to the septum membranaceum between the sacculus and 
the utriculus, and to the macula cribrosa, and then enters the first turn 
of the lamina spiralis, from which point it continues its course through- 
out all the windings of the spiral lamina. 

Ampullar Branches. — Duval and Laborde^ showed that some of the 
fibres of the auditory nerve originate in a collection of motor cells in the 
bulb, and further, that these fibres are continued in the inferior cerebel- 
lar peduncles. The conclusion, therefore, is that there are two sorts of 
fibres in the auditory nerve, — viz., sensory and motor, — and the branch 
possessing the latter function sends fibres to the ampullae as well as to the 
cerebellum, and thus may be explained the reflex phenomena of disturbed 
equilibrium from irritation in the ampullae and semicircular canals. 

Inner and Outer Nerve- ends of the Cochlear Branch. — The ultimate flbres 
of the auditory nerve in the cochlea are named the inner and the outer 
terminal filaments, in accordance with their distribution to the inner and 
outer hair- cells. 

According to Waldeyer, both sets of fibres, as they emerge from the 
openings in the lamina spiralis ossea, pass through the ^' granular layer" 
which lies directly over their point of exit. The inner nerve-fibres then 
pass directly to the inner hair- cells. These fibres are large, and are con- 
sidered as true axis-cylinders. The outer nerve-fibres are distributed, as 
shown by Gottstein, between the pillars of Corti, at about half the height 

1 De r Oreille, etc., Gelle, Paris, 1881, p. 323. 



ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. 69 

of the arches, to the inner tow of the outer hair-cells, and perhaps to the 
more distant rows (Fig. 51, s). 

The origin of the auditory nerve, being so near the origin of the 
pneumogastric nerve, will help to explain the sympathy which seems 
to exist between an aural disease and the respiratory and digestive 
tracts. 

There also seems to be a sympathy between the ear and the emotions. 
May not cases of apparently hysterical deafness be traced to some such 
central nervous connection '? 

Soft Farts of the Yestibide and the Semicircular Canals. — Eiidinger^ has 
shown that the sacculi and membranous semicircular canals of the in- 
ternal ear are in direct contact with the osseous or cartilaginous struc- 
tures containing them, and that, therefore, they do not float, as heretofore 
supposed, entirely free in the i)erilymph. The periosteum lining the 
bony cavity containing these membranous parts is a moderately thick 
layer of connective tissue with some fine elastic fibres. 

The Sacculi. — The utriculus is more closely connected to the inner 
wall of the vestibule than is the sacculus rotundus. The two sacculi oc- 
cupy two -thirds of the cavity of the vestibule. The utriculus extends 
farther outward towards the tymjianum, but neither of them touches 
the side of the vestibule which receives the base of the stapes, — i.e.. they 
do not touch the outer wall of the vestibular cavity (Plate L, 10 and 19). 

The 2Ieml>ranous Semicircular Cancds. — These are fastened to the convex 
side of the bony canals by means of stout connective-tissue fibres, which 
are called by Eiidinger the ligamenta labyrinth i canal iculor urn. These con- 
stitute the true supi)ort of the membranous canals. Sometimes there are 
two or more of these connective-tissue stays, so arranged as to simulate 
under the microscope transverse sections of small canals. But they are 
to be regarded simply as j^art of the support of the membranous semi- 
circular canals (Fig. 52, h). 

Another set of connective-tissue fibres, passing from the periosteum 
to the free surface of the labyrinth wall, are for the purpose of supporting 
the blood-vessels as well as supplying points of fixation for the free wall 
of the membranous labyrinth (Fig. 52, d). 

The wall of the membranous semicircular canals has an unequal 
thickness, being 0.016 of a millimetre thick at the point of contact with 
the periosteum and from 0.06 to 0.08 of a millimetre thick at the point 
of junction with the ligamenta labyrinthi canaliculorum. The canal wall 
is composed of four layers in the following order, from without inward, 
— viz., 1, a layer of connective tissue ; 2, hyaline tunica propria ; 3. papil- 
liform prominences ; and, 4, the epithelium. 

The external layer possesses all the qualities of connective tissue with 
numerous cells. A'\Tien the entire membranous semicircular canals, 

^ Das haiitige Labyrinth, Strieker's Handbuch, Leipzig, 1872. 



70 



DISEASES OF THE EAR. 



removed from their connection with the periosteum and ligaments, are 
subjected to examination, another net- work is found closely resembling 
nerves and ganglia. But it is as yet very uncertain whether these are 
nerve-elements, since the existence of nerves in the membranous semi- 
circular canals is doubtful. The tunica propria is of unequal thickness in 
the semicircular canals, but in the utriculus it is of uniform as well as 
great tenuity. The papilliform prominences on the inner surface of the 
tunica propria are by Eiidinger regarded as normal structures in the 
adult human being (Fig. 52, c). The papillae are covered with pave- 

FiG. 52. 




Section through the osseous and membranous semicircular canals. (Politzer.) a, osseous semicir- 
cular canal ; 6, place of attachment of the membranous semicircular canal ; c, elevations on the inner 
surface of the membranous semicircular canal ; d, vascular bands of connective tissue. 



ment epithelium, which is so easily detached that some observers have 
failed to find it at this point. These bodies are not found in the sacculi, 
nor at that part of the semicircular canals where the latter pass into the 
utriculus. 

Sacculi and Ampullce ; Inner Surface. — On the inner surface of these 
organs may always be found a peculiar yellowish epithelium provided 
with cilia. There is also a reduplication of the tunica propria extending 
into the cavity of the ampullae, to which the name of crista acustica has 
been given by Max Schultze. A similar projection in the sacculi is 
called by the same authority the macula acustica (Plate I., 9 and 14). 

Every branch of the acoustic nerve going to the ampullae, after 
dividing into two flat fasciculi supplied with ganglion cells, passes 



AXATOMY AXD PHYSIOLOGY OF THE IXTERXAL EAR. 71 

through the tunica propria, aud is then distributed to the ciliated epi- 
thelium of the crista acustica. 

FJanum Semilunare. — At right angles to each end of the crista acustica, 
extending along the walls of the ampullae, there is an elevation on the 
epithelial layer, named the planum semilunare.^ To this also some of 
the terminal filaments of the auditory nerve are conveyed, as shown by 
Eiidinger. 

The epithelial layer in the sacculi is thinner than that in the ami3ullj]e, 
and contains several varieties of epithelium. But here, too. ciliated cells 
are found, to which nerve-filaments are sent. 

The Otoliths. — In the endolymph of the sacculi are found small crystals 
of carbonate of lime, called otoliths. Some observers have found otoliths 
in the endolymph of the semicircular canals and in that of the cochlea, 
but these are generally considered exceptional occuiTences. Henle, after 
treating the otoliths with acids, thought he detected a cartilaginous rem- 
nant, to which the name of otolith cartilage is given. They are. accord- 
ing to Eiidinger, large and few in reptiles, but small and numerous in 
man and other mammals. 

The Tojwgrajyhical Arrangement of the Soft Farts of the Internal Far. — 
By consulting Plate I. the general relations between the soft parts of the 
internal ear may be learned. It will be seen that the sacculus rotundus 
pertains more to the ductus cochlearis than to the utriculus and the rest 
of the so-called membranous labyrinth. The link between the sacculus 
and the ductus cochlearis is the canalis reuniens of Hensen (Plate I., 28). 

The aquieductus vestibuli is the roundabout way from the utriculus to 
the sacculus. Of this peculiar duct more will be said hereafter. The 
utriculus, as shown in the diagram, is the cavity with which the mem- 
branous semicircular canals and their important ampuUce are in close 
connection. The entire membranous labyrinth is filled with endolymph. 

The Endolymph. — The general plan upon which the endolymph and 
perilymph of the inner ear are renewed has been best explained by 
Hasse, of Wiirzburg. ^ He has shown that all vertebrates possess a duct 
which originates in the vestibule ; and in all animals, with the exception 
of the plagiostomes, in which it passes directly to the surface of the skull, 
this duct enters the cavity of the cranium, and there terminates either in 
a closed sac at the confines of an epicerebral lymph- cavity or opens into 
the same. This is the ductus endolymphaticus or the aquseductus vestib- 
uli, with the saccus endolymphaticus, the former of which arises from 
the sacculus rotundus in most vertebrates, and conveys endolymph to the 
membranous labyrinth. 

FhysiologieaJ Functions. — Hasse has suggested three probable functions 
of the aquseductus vestibuli, or the endolymphatic duct (Plate I., 27 t. 

^ Steifensand, 1835. 

^ Anatomische Studien, Xo. 19, S, 768. 



72 DISEASES OF THE EAR. 

1. The endolymphatic duct and its sac are the source of the endolymph 
in embryonal life. In this capacity the sac plays the part of a gland. 

2. In adult life this duct may act as a conveyer of new material to the 
endolymph, either by endosmosis from the epicerebral cavities in those 
instances where the saccus endolymphaticus is closed or by means of a 
direct current where the saccus is open. 

3. It may be supposed that the sac is useful as a reservoir for the 
liquor endolymphaticus when the intralabyrinthine pressure becomes ex- 
cessive. By the reception of the fluid into this sac the pressure would be 
reduced in the labyrinth. 

A very practical deduction is made by Hasse respecting the ductus 
endolymphaticus. Every increased or diminished pressure of the cerebro- 
spinal fluid in the subarachnoid cavity will make itself felt by continuity 
through the saccus and the ductus endolymphaticus, in the interior of the 
auditory apparatus, in the endolymphatic cavity, and upon the terminal 
filaments of the auditory nerve. Thus may be explained the impairment 
of hearing for high notes when the pressure in the labyrinth is increased. 
Furthermore, pathological processes in the subarachnoid space are con- 
veyed, either by continuity or contiguity, through the saccus and ductus 
endolymphaticus, into the interior of the labyrinth, and vice versa, the 
latter being the rarer, from the deep-seated position of the inner ear. 
Thus, every alteration in the chemical constitution of the cerebro-spinal 
fluid necessarily produces a change in the liquor endolymphaticus, which 
alteration may exercise some influence in the occurrence of subjective 
acoustic perceptions, but in any event must change the composition of 
the endolymphatic fluid. 

The Ferilymph. — The perilymph is poured into the labyrinth from the 
subarachnoid space through the foramina acustica (Fig. 49, a), and leaves 
the labyrinth by means of the aquseductus cochleae (Fig. 30, 17). The peri- 
lymphatic cavity exists in the lymphatic tract of all vertebrates,^ and, 
being in connection with the subarachnoid space, it is easily seen how 
changes of any kind in the cerebro-spinal fluid may be communicated 
to the perilymph and thence to the organ of hearing. Hence morbid 
processes in the subarachnoid space may be communicated to the organ 
of hearing either by the perilymphatic or the endolymphatic tract, or 
by both ways at the same time. In this manner a plausible explanation 
may be given of numerous affections of the internal ear. 

Hasse reiterates his views on the endolymph and perilymph in an 
article in the ArcMv filr Ohre?iheilkunde, March, 1881, Bd. xvii. Heft 3, 
S. 194. 

PHYSIOLOGrY. 

Cochlea. — The physiology of the perceptive part of the organ of hear- 
ing has been explained most satisfactorily by Helmholtz and Hensen, the 



^ Hasse, op. cit., p. 815. 



ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. 



73 



latter having made a series of experiments upon the function of hearing 
in the crab and lobster, since upon the surface of these animals there are 
largely developed cilia, endowed with x^eculiar vibratile functions, and 
probably connected with the organ of hearing. 

It is now generally supposed that the cochlea enables man to perceive 
musical notes, or notes and sounds with regular periodic vibrations, and 
that the membranous labyrinth is concerned in the perception of irregular 
vibrations, which are distinguished as noises. In the labyrinth the dis- 
tribution of the acoustic nerve may be traced to particularly firm and 
elevated spots at five different points, — viz., in the two sacculi and three 
ampullae. 




SCHEME OF RELATIONSHIP BETWEEN THE MIDDLE AND INTERNAL 

EAR. 

Schematic Descri/ption of the Middle Ear, of the Internal Ear, and of the 
Relation they hear to Each Other. — In order to understand the general 
features of the middle ear and of the internal ear, and the general rela- 
tion they sustain to each other, let there be imagined, first, a broad and 
shallow barrel, closed at each 

end and divided transversely in Fig. 53. 

the middle by a partition. 

If this barrel be laid upon its 
side with one end towards the 
reader, it will give a fair repre- 
sentation of the middle ear in the 
near half and of the internal ear 
in the far half The head of the 
near half of this barrel will rep- 
resent the membrana tympani or 
drum-head, while the partition 
in the centre of the barrel repre- 
sents the inner bony wall of the 
tympanic cavity. In this parti- 
tion make an oval opening, and 
below and behind this a round 
one. The former represents the 

foramen ovale, or the oval window, and the latter, the foramen o'otundum, 
or the round window. 

From the membranous head of the near half of the barrel to the par- 
tition in the centre is stretched a bony bridge composed of three pieces, 
— viz., the malleus, or mallet, the incus, or anvil, and the stapes, or 
stirrup. 

The handle of the outermost of the three ossicles, the manubrium of 
the mallet, is inserted into the fibrous or middle layer of the drum-head ; 
the innermost, the stirrup, by means of its foot-plate, fits into the ova] 



Horizontal section through the left auditory appa- 
ratus, viewed from above ; photographed from nature. 
a, mastoid cells ; b, aditus and antrum ; c, stapes in oval 
window of vestibule ; d, vestibule ; e, internal auditory 
canal for acoustic nerve ;/, vertical section of cochlea, 
through modiolus ; g, cochlear process for tendon of 
tensor tjTnpani : tendon passing to malleus ; h, mem- 
brana tympani; i, descending limb of incus, joining 
stapes ; k, malleo-incudal joint ; I, outer wall of attic. 



74 



DISEASES OF THE EAR. 



window in the inner wall of the tympanic cavity, and the middle bonelet, 
the anvil, is held in position between the other two. They are further- 
more held together and fastened to the roof and wall of the tympanic 
cavity by means of ligaments (Figs. 30 and 54). 

This bridge of ossicles may be said to have two guys which steady it 
and give it proper tension, one of which is fastened to the mallet and 
the other to the stirrup. The former will at once be recognized as the 
tensor tympani and the latter as the stapedius muscle. 



Fig. 54. 



IXJLH.Tn 




uj>}^ 



Profile view of the left tympanum and part of the internal ear, from before and somewhat from 
above, the anterior part having been cut away ; magnified four times. (After Quain.) m, head of the 
malleus ; sp, lower anterior part of the prominent border of the articular surface ; pr.hr, short pro- 
cess of the malleus ; pr.gr, root of the processus gracilis, cut ; s.l.m, suspensory ligament of the malleus ; 
l.e.m, external ligament of the malleus ; t.t, tendon of the tensor tympani, cut ; i, incus, and below its 
process ; st, stapes in the fenestra ovalis ; e.au.m, external auditory meatus; pR, incisura Rivini ; m.t., 
membrana tympani ; u, umbo of the membrana tympani ; d, pouch between the membrana tympani 
and the lower wall of the external auditory canal ; i.au.vi, internal auditory canal ; a, b, upper and 
lower divisions of the parts of the auditory nerve ; n.p, canal for the posterior ampullar nerve ; s.s.c, 
ampulla of superior semicircular canal ; p, posterior ampulla ; c, common crus of the superior and pos- 
terior semicircular curves ; e.s.c, external ampulla ; e.s.C, external semicircular canal ; s.t.c, scala tym- 
pani cochlepe ; f.r, fenestra rotunda, closed by the membrana tympani secundaria ; a.F, aquseductus 
Fallopii, or facial canal. 



In the outer half of the imaginary barrel are two bung-holes, one in 
front, the other on the back. The front bung-hole represents the tym- 
panic opening of the Eustachian tube, by means of which the middle ear, 
or drum, is ventilated and the atmospheric pressure on each side of the 
drum-head equalized. The back bung-hole is the communication between 
the mastoid cells and the cavity of the tympanum (Fig. 34, c and g). 

The mastoid portion may be likened to an ivory box filled with 
sponge, the latter representing the series of bony cells, which communi- 



ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. /O 

cate with one another and at last, by means of the tympanic antrum, 
with the cavitj^ of the middle ear. In this simple manner the middle 
ear, with its ossicles and more important appendages, may be sketched. 
The functions of this cavity are dependent on aerial life and equal 
pressure of air on each side of the drum-head. 

This air-containing cavity is separated from the internal ear, or laby- 
rinth, a icafer-containing cavity, by means of a bony x)artition, — viz., the 
inner wall of the middle ear already described, — in which is the oval win- 
dow into which the foot-plate of the stirrup fits. Hence these two im- 
portant cavities have one wall in common through which, by means of 
the foot-plate of the stirrup, the movements of the chain of little bones 
are communicated to the fluid of the internal ear and to the thread-like 
ends of the nerve of hearing suspended in it (Fig. 54, st). 

In order to understand the general features of the internal ear, let us 
still retain the simile of the bai-rel. In this instance the inner half of the 
barrel must be regarded as made entirely of bone, as filled with water, 
and as communicating at no point with the atmosphere, but in direct 
communication with the arachnoid space by means of the aqueducts of 
the vestibule and cochlea. 

As the walls of the internal ear are made of bone, there can be no 
yielding on their part to the jDressure of the fluid of the labyrinth pro- 
duced by the movements of the stapes. In order that these movements 
may go on, there exists at the extremity of one of the passages of the 
internal ear — viz., the cochlea — the round window, over which is 
stretched a membrane which yields slightly to the pressure brought about 
in the labyrinth by the movements of the stapes. 

On the front of this inner cavity representing the interned ear is a 
spiral tube with two and a half turns. Being coiled like a snail-shell, it 
long ago received the name of cochlea. 

On the back of this inner cavity are five openings communicating 
with three semicircular tubes. We would naturally look for six ox)eu- 
ings into the ends of thi^ee semicircular tubes, but only five are found in 
this instance, as two ends of two of the semicircular tubes — viz., the 
superior and posterior semicircular canals — join together and have a 
common 0]3ening into the internal ear or labyrinth at that part of it called 
the vestibule (Plate I.). 

On the farther wall of this inner space we find the nerve of hear- 
ing entering the labyrinth through a sieve-lil-e sjwt. After pushing 
its way into the cavity of the internal ear through this sieve-like spot in 
the inner bony wall of the internal ear, at the fundus of the internal 
auditory canal, the auditory nerve divides into two main branches, one 
of which, the cochlear branch, is distributed to the cochlea, and the 
other, the vestibular branch, is given to the sacculi and to the ampullae 
of the semicircular canals (Plate I.). 



CHAPTEE YIL 



INSTRUMENTAL EXAMINATION OF THE EAR. 



Source of Light — Tlie light used in examining the ear may be sun- 
light, electric light, gas-light, or lamp- or candle-light. These may be 
used either directly or by reflection. 

Reflected Light. — The most usual method of illuminating the external 
auditory canal and the membrana tympani is by reflecting the light from 
a mantle gas-burner into the ear through aural specula, by means of mir- 
rors yet to be described. The flame of the light thus used should be 
about four and a half feet above the floor, and the patient should sit 
beside it, with the ear to be examined turned away from the light. 



Fig. 55. 








Forehead electric lamp in position. 



Hand otoscope, one-half natural size. 



Direct Light. — Direct sunlight may be thrown into the ear after the 
patient is placed favorably for this purpose, or the external canal and the 
membrana tympani may be illuminated by direct light from an electric 
lamp held on the surgeon's forehead, as shown in Fig. 55. Electric illu- 
mination by this means is the only form of artificial light that can safely 
be brought near the ear of the etherized patient. 

76 



INSTRUMENTAL EXAMINATION OF THE EAR. 



77 



Ear-Mirror^ or Otoscope. — The instruments used in the ocular exami- 
nation of the ear should be as simple as possible. They must consist of 
at least a concave hand-mirror with a focal distance of from four to six 
inches, and a nest of four so-called specula, or ear-funnels. That form 
of hand otoscope known as von Troeltsch's ear -mirror is the simplest 
and the best (Fig. 56). 

The Forehead Ear -Mirror. — Equally as important as the hand ear- 
mirror is the forehead ear-mirror. It consists in the attachment of the 
same kind of a mirror as the former firmly to a forehead band of inelastic 
silk. There are many forms of attachment, but a ball-and-socket joint, 



Fig. 57. 




Illumination of the ear by means of the forehead-mirror during insufflation of a powder. 



that can be tightened or loosened as required, in which the ball of the 
joint is close to the i^eriphery of the mirror, and in which the joint lies 
in the centre of the band, is the best, because, with the mirror thus 
brought so near the point of fixation, the greatest firmness is obtained. 
It is not necessary — in fact, it is best not — to endeavor to look through 
the hole in the centre of the mirror when on the forehead, but to look 
under it or to one side of it. In every instance the mirror must first be 
adjusted with the hand, so as to throw the light to the best advantage 
into the speculum and canal. Then the operator can keep up the illumi- 
nation of the ear by holding the mirror in the desired position by his 
head, while his hands remain free. The manner of its use can be seen 
by consulting Fig. 57. 

Otoscopes, or Aural Specula. — The next want will be a nest of specula 
or ear-funnels. There are numerous forms found in the instrument- 
makers' shops, under the names of Kramer, Toynbee, Wilde, Gruber, 




78 DISEASES OF THE EAE. 

Politzer, and others. While all are good, preference should be given to 
Gruber's specula, because a transverse section of their caliber at right 

angles to the long axis most closely re- 
sembles a similar section of the auditory 
canal, — i.e., it is slightly ovoid in shape. 
The great object in using a speculum 
or aural funnel is simply to hold the 
tragus away from the meatus, and to 
IDUsh away the stiff hairs about the 
Gruber's aural specula. Opening of the external auditory canal. 

In some cases moderate dilatation of 
the cartilaginous canal may be effected, but usually all endeavors at 
dilatation of the external auditory meatus are worse than useless, — tJiei/ 
are painful and injurious. 

Siegle^s Fneumatic Otoscope. — Siegle's pneumatic otoscope consists of 
a hard rubber, round speculum, like Politzer' s, to which is attached an 
air-tight chamber three centimetres in diameter. The upper or outer 
wall of this chamber is of glass, and forms an angle of forty degrees with 
the i^lane of the inner wall. On the longer side of the chamber there 
is an opening with a x)erforated knob, to which is attached a piece of 
rubber tubing about a foot in length, ending in a mouth-piece for the 
surgeon. This chamber is made to screw on and off ear-funnels of 
different diameters. When all the parts are fully adjusted, the surgeon 
has an air-tight speculum with a glass end, through which he can exam- 
ine the movements the drum- membrane makes during condensation and 
rarefaction of the air, brought about by his own mouth through the rub- 
ber tubing at the side of the instrument. This is really the only means 
the surgeon has of fully determining the mobility of the drum-head, 
though both Valsalva's and Politzer' s methods of inflation, if carried 
out while the surgeon's eye is fixed on the drum-head, will give him 
some idea of the extent to which the membrane can move. But when 
the Eustachian tube is impervious, Siegle's instrument is the only means 
of determining the mobility of parts or of the whole of the membrana 
tympani. Gorham Bacon improved this instrument by adapting to the 
air-chamber Gruber's specula in place of round ones. 

BurneWs Modification of SiegWs Fneumatic Otoscope. — This is prac- 
tically a metallic Gruber speculum transformed into a Siegle pneumatic 
speculum, or otoscope, by the addition of a glass lid (Fig. 59). Its 
extreme length is five and one-half centimetres, and its diameters at its 
meatal end are six millimetres vertically and four millimetres horizon- 
tally. This renders it more adaptable to the shape of the meatus. It is 
nickel -plated both within and without, which gives it a better reflecting 
surface than that i)ossessed by black instruments. Two small openings 
on its inner wall, at the point of junction with the air-tube, act like a 
sieve, to prevent the drawing up of particles of cerumen or dirt into the 




INSTRUMENTAL EXAMINATION OF THE EAR. 79 

operator's moutli, another advantage over the ordinary Siegle instru- 
ment. The attachment for the air-tube is on the lower side of the 
speculum, so that there is only a gentle vertical curve of the suction-tube 
instead of the double bend which existed in the old form of the Siegle in- 
strument with the air-tube at- 
tachment at its side. The Fig. 59. 
chief advantage, however, lies 
in the meatal end of the spec- 
ulum, which rapidly widens 
for a distance of a centimetre 
from the end to a diameter of 
eleven millimetres vertically 
and ten millimetres horizon- 
tally, thus giving a graduated 
end fitting hermetically into 

any adult meatus without the Burnett's modification of Siegle's pneumatic otoscope. 

necessity of adding rubber 

packing or substituting another speculum with smaller or larger diame- 
ters, as in using the old forms of the hard-rubber Siegle otoscope. 

Fosition of Fatienfs Body and Head. — The most usual way of examin- 
ing the ear is by reflected light (page 76). The patient may lean back or 
sit high and straight in the chair, but the axis of his body should be in- 
clined neither to the right nor to the left. His head should be inclined 
somewhat towards the shoulder opposite to the ear to be examined. It is 
important for the comfort of the examiner that the body of the patient 
should not be inclined away from him, for if it be, a great strain comes 
on the back of the surgeon in his endeavor to reach after the ear. 

Fosition of Surgeon. — Tlie surgeon, standing beside the patient, in 
front of the ear to be looked into, should grasp the auricle at its upper 
and posterior margin gentlj" between the index and middle fingers of 
his left hand, and pull it a little upward and backward. This is al- 
ways to be done with the left hand, no matter which ear is examined. 
This leaves the right hand free to hold the mirror. The patient should 
be placed, and the surgeon should stand, so that the light may fall on the 
mirror towards the surgeon's right side or directly from in front — 
never from the left — in the above position of patient and examiner. 
These rules as to i^osition of light, patient, and physician are especially 
important when artificial and I'eflected light is used. 

Insertion of Ear- Speculum. — With the auricle grasped as directed 
above, between the index and middle fingers of the left hand, the specu- 
lum or ear-funnel may be gently inserted in a direction slightly downward, 
inward, and forward, or in general terms towards the patient's nose, by 
the other hand, and then grasped at the edge of the wide end by the 
thumb and index of the left hand. Or it may be inserted by the thumb 
and index of the left hand at the same time that the index and middle 



80 DISEASES OF THE EAR. 

fingers grasp the superior posterior margin of the auricle. In the latter 
instance a very gentle and slight rotation will suffice to place the ear- 
fannel properly. The speculum being now in the meatus, light is to be 
reflected into it from the mirror. 

The first point to be determined, in making an examination of the 
ear, is whether or not the auditory canal is entirely free from obstruc- 
tion. If it is, the eye of the observer should, after ascertaining the 
state of the wall of the canal, seek the membrana tympani. The chief 
obstacle in such a search is usually the misdirection of the axis of the 
funnel. This, instead of being made to correspond with the axis of the 
auditory canal, is by the unskilled usually so directed that the light falls 
upon the sides of the canal or only partially on the drum-head. Hence 
it is not at all uncommon to hear a diagnosis made for the membrana 
tympani which is based entirely on a view of the condition of the skin 
lining the auditory canal. 

What should be seen at the fundus of the canal is described on pages 
16 to 20, yet it will be a long time before the eye can so accommodate itself 
to the conditions of illumination in the external ear as to interpret fully 
what it sees. The experienced eye is able to resolve into depressions, 
elevations, curves, etc., things which to a beginner seem to be entirely in 
the same plane. 

Fig. 60. 




Forceps for removing foreign bodies from the ear. 

Bemoval of Obstacles to a Vieiv of the Membrana Tympani. — It requires 
but a small object — a few stiff hairs or a flake of cerumen or of epithe- 
lium — to obstruct the view of the drum-head. All such obstacles are 
most easily removed by a few syringefuls of warm water, which will, 
however, render the drum-head a little macerated, and thus deprive it of 
whatever lustre it may have had. This must be borne in mind in looking 
at the drum-head after warm water has been syringed upon it. There- 
fore, when it is especially desirable that the amount of natural lustre in a 



IXSTRUMEXTAL EXAMIXATIOX OF THE EAR. 



81 



Fig. til. 




given case should be estimated, an obstructive sub.stance might better be 
gently and most carefully lifted or viped out of the canal. The former 
is most readily accomplished by the slender forceps shown in Fig. 60, 
while the canal is thoroughly illuminated by the forehead-mirror (Fig. 
57). If the obstruction to vision can be wiped or swabbed out. the 
cotton-holder, with its little wad of cotton at the roughened end. will 
enable one to do this. 

The Cotton-RoJder.—This, is a most useful instrument^ both for cleansing 
the ear and for conveying medications to diseased surfaces in the organ. 
The shaft is flexible for an inch or two and roughened at the 
tij), around which a small tuft of absorbent cotton may be 
coiled, and then used, as already indicated, for cleansing 
and treating the ear. The cotton is removed from the holder 
by twisting it off in the direction opposite to that in which 
it was wound on, or it may be burnt off (Fig. 61). 

During all these procedures for removing small obstruc- 
tions to a good view of the drum-head the canal is supposed 
to be most carefully illuminated by light reflected from the 
forehead-mirror, and the operations performed by a skilled 
hand. 

If the methods suggested should be inadequate to remove 
obstacles in the auditory canal, recourse may be had to 
syringing. The springe should be carefully chosen : one 
that holds two fluidounces will be large enough, though both 
larger and smaller ones may be used. The syringe should 
work perfectly, being neither too loose nor too tight in the 
piston. There is an excellent syringe for am^al purposes 
always at hand in the hard-rubber enema syringe. Xo. 2. At 
this point it may be said, unhesitatingly, that all forms of 
syringes sold in the drug-stores and elsewhere, under the 
high-sounding name of ''ear-syringes." are uniformly dear 
and as uniformly worthless. 

Syringing the Ear. — In syringing the ear. cold water must 
never be used. Let the water be pleasantly warm. A china 
basin with a partition dividing it into two compartments 
should be employed. The clean water should be in the side 
nearest the stugeon, the empty compartment under the pa- 
tient's ear to catch the return current. Provided with an 
asexitic syringe, as well as with a receptacle for holding and 
catching the water, let the suigeon grasp the auricle between 
the thumb and forefinger of the left hand and pull it gently 
uiDward and backward. TTith the auricle thus held, let the cotton-hcidt 
syringe be emj)tied slowly but firmly into the auditory 
meatus. Point the syringe downward and forward towards the patient's 
nose. The current fi^om the syringe should be thrown along the upi)er 



DISEASES OF THE EAR. 



Fig 




wall of the auditory canal, tliiis permitting the return current to pass 
along the floor of the canal. 

In some cases considerable force may be used in throwing 
the current of water into the canal, as, for example, when 
it is desired to remove a foreign body from the fundus of the 
canal or when the canal is blocked up with a large and ad- 
ff herent wax plug. I have found it decidedly advantageous 

it to give to the syringe a gentle siDiral motion as the current 

of water is going into the meatus. This impulse conveyed 
to the water will thoroughly wash off all adherent matters 
from the wall of the auditory canal. 

Examination of the Nares and Fauces, Throat, and Eustachian 
Tube. — The inspection of the nares, fauces, and throat, and 
the examination of the state of the Eustachian tube form a 
most important adjunct to a complete aural examination. 

Eustachian Catheters. — The ocular examination of the 
Eustachian tube ceases with the rhinoscopic view of the fau- 
cial extremity ; beyond that point the examination becomes 
entirely aural, by means of the Eustachian catheter and the 
auscultation-tube. The Eustachian catheter consists of a 
tube of metal or hard rubber, curved at the beak as seen 
in Fig. 62, a. The conical handle must be made so as to per- 
mit the end of the air-bag to fit accurately into it, and the 
ring or button (Fig. 62, 1)) upon the handle should be firmly 
attached to each instrument in the same plane with the 
circle of which the curved beak is an arc. By observing 
the position of the button or ring-indicator, one can always 
know the precise position of the beak of the catheter. 

The Auscultation- Tul)e. — This instrument is the highly 
important adjuvant of the Eustachian catheter 5 in fact, in 
so far as the latter is of aid in an objective examination, it 
owes that power to the auscultation-tube. The latter con- 
sists of a yard of rubber tubing, eight millimetres in its 
outside diameter. Black rubber tubing is preferable, being 
more lasting and less sulphurous in odor than the ordinary 
domestic white rubber tubing. Upon one end of this tube 
there should be a white bone end-piece made to fit the 
surgeon's ear ; at the other end there should be a black 
end-piece for the patient's meatus. In using the ausculta- 
tion-tube, one end should rest snugly in the meatus of the ear catheter- 
ized, while the other end must rest equally well, though not too tightly, 
in the examiner's ear. 

Let it be supposed, for example, that the patient's left ear is to be 
catheterized, and that the auscultation- tube is also to be used. Let the 
examiner place his end of the auscultation-tube in his left ear and bring the 




Eustachian cath 
etei; 



IXSTRUMEXTAL EXAMINATION OF THE EAR. 



83 



tube loosely around behind his neck and over his right shoulder, placing 
the other end of the tube in the patient's left ear. If the tube be thus 




Auscultation-tube . 



supported, it is less in the way of the surgeon and less likely to fall either 
out of his or the patient's ear. 

The method usually given in most works on aural surgery is to allow 
one end to rest, for instance, in the patient's left ear, while the other end 
is resting in the surgeon's right ear. In such a case not only will the 
tube hang down between the patient and surgeon and be in the way, but 
its mere weight when thus suspended is sufficient to drag it out of i^lace. 



Fig. 64 




Hand inflation-bag in the Eustachian catheter. 



The Rand Inflation- Bag. — The general appearance of the hand inflation- 
bag is shown in the hand of the surgeon in the annexed figure (Fig. 



84 DISEASES OF THE EAR. 

64). The use of this bag is to force air through the catheter into the 
Eustachian tube and tympanic cavity. It is of the greatest importance 
that the end-piece, or so-called ''mount," at the distal end of the bag 
should fit accurately into the catheter, and, like it, be of hard rubber. 
During the expulsion of the air from the bag, great care should be taken 
not to force the axis of the bag out of line with that of the catheter, for, 
should this occur, either by an upward or downward movement of the 
hand and wrist, the catheter, if of hard rubber, will be very apt to break ; 
if of silver, to bend. In compressing the air-bag, no motion should 
occur, except in the fingers of the right hand or the hand employed in 
compressing the bag. A little practice will enable the operator to make 
only such a motion with the fingers, though at first there is an almost 
involuntary tendency to flex the hand laterally on the wrist towards the 
ulna at the same moment that the fingers are made to squeeze the bag. 
The bag must be removed from the catheter after each inflation, in order 
to renew the air in it. Any other form of inflation whereby this removal 
is obviated tends to draw fluids from the nares into the catheter. 

Catheterization of the Eustachian Tube. — Provided with the three in- 
struments described in the preceding pages, — viz., a catheter, an auscul- 
tation-tube, and a hand air-bag, — the surgeon may endeavor to catheterize 
the Eustachian tube by placing the beak of the Eustachian catheter in 
the faucial end of the Eustachian tube, so as to enable him to force air 
into the latter and thence into the tympanic cavity. In catheterizing the 
Eustachian tube the patient may sit or stand. It is preferable that the 
patient sit with his hips well back in the chair and his sj)iual column 
and head erect. The latter may be placed against the wall or the back of 
a chair should the latter come above the patient's head. Then, with the 
auscultation- tube adjusted as described, the surgeon should place the 
fore- and middle fingers of the left hand on the patient's forehead a little 
above the root of the nose, and with his thumb should lift up the tip 
of the patient's nose and hold it up until the catheter is well inserted. 

With the tip of the patient's nose held as just described, let the sur- 
geon grasp the catheter as he would a pen-holder, between the thumb and 
forefinger of the right hand, holding his hand down about as low as the 
patient' s chin, towards which the palm of the catheter hand should be 
turned, ^ow insert the beak of the catheter into the nostril correspond- 
ing to the ear to be catheterized, and with a comiDound upward and for- 
ward motion pass the instrument along the floor of the nose until the 
beak reaches the nasopharynx and at last touches the posterior pharyngeal 
wall. The ring or button at the j)roximal end of the catheter, which the 
surgeon always keeps in sight, should point directly downward upon the 
arrival of the catheter beak in the nasopharynx. With the catheter' s dis- 
tal end at the posterior pharyngeal wall, the beak may be turned outward 
towards the ear to be catheterized. By this motion the beak will slip 
into the fossa of Eosenmliller (Fig. 65, g). At this x>oint there is usu- 



INSTRUMENTAL EXAMINATION OF THE EAR. 



85 



ally made the mistake of supposing that the catheter's beak rests in the 
mouth of the Eustachian tube, and consequently unsuccessful attempts at 
iniiation are made. But in order to i)lace the beak of the catheter in the 
mouth of the Eustachian tube the following manipulation becomes neces- 
sary. After the beak of the catheter has been turned into the fossa of 
Eosenmliller, draw the catheter forward, letting the beak slip over the 
posterior lip of the Eustachian tube (Fig. 65, Ji), and as this is done 
turn the catheter so that the ring- indicator will point towards the ear 
catheterized at an angle of forty-five degrees. At the moment this 



Fig. 65. 




Vertical section of the nasopharynx, with the catheter introduced into the Eustachian tube, right 
side, a, inferior turbinated bone ; 6, middle turbinated bone ; c, superior turbinated bone ; d. liard 
palate ; e, velum palate ; /. posterior pharyngeal wall ; g, Rosenmuller's fossa ; h, posterior lip of the 
orifice of the Eustachian tube. 

movement is made with the catheter, its beak slips into the faucial ex- 
tremity of the Eustachian tube (Fig. 65). This is not easily done ; but 
fortunately it is an operation rarely if ever needed, and should never be 
performed except by an expert in aural surgery. 

Fixation of the Eustachian Catheter. — After the catheter has been thus 
X^ut in place, let the thumb and forefinger of the left hand grasp the in- 
strument close to the nose, while the remaining three fingers are braced 
above the root of the patient's nose at the point formerl}^ occupied by the 
middle and index fingers during the elevation of the tip of the nose by the 
left thumb and the insertion of the catheter by the right hand (Fig 64). 

With the catheter thus fixed in position, and the auscultation-tube 



86 



DISEASES OF THE EAR. 



Fig. 66. 



passing from the patient' s ear to the ear of the examiner, the latter may 
grasp the hand air-bag and make inflations into the tube and tympanum. 
If the Eustachian tube is pervious, air will be heard to enter it with 
more or less force. As a rule, two or three inflations from the air-bag 
will be sufficient to properly and safely ventilate the middle ear. In 
using the Eustachian catheter the greatest danger is from emphysema of 
the nasopharynx and pharynx, even including the glottis. This will not 
occur, however, if the mucous membrane of the mouth of the Eustachian 
tube has not been lacerated and the air-bag then used with great ex- 
pulsive force. 

Inflation of the Tympana by Folitzer^s Aiy^-Bag. — Politzer's hand air- 
bag consists chiefly of an ordinary air-bag such as is used for forcing air 
through the Eustachian catheter. Instead of the conical tip of the ordi- 
nary hand air-bag, the instrument devised by Politzer is supplied with a 
somewhat bulbous tip, to which is attached a piece of black rubber tube 
eight centimetres long, which forms the pliable connection between the 

air-bag and the nose-piece. The latter piece 
is made of hard rubber, and varies from three 
to four millimetres in diameter. It is curved 
slightly at the beak, and resembles at this 
point a coarse Eustachian catheter (Fig. 66). 
In fact, one may extemporize a Politzer's appa- 
ratus by attaching an ordinary hard -rubber 
catheter to the hand air-bag ; but in this case 
the disadvantages are the stifl'ness of the 
catheter and its great liability to snap in half. 
Politzer's method of inflation depends upon 
the i)hysiological fact that, at the moment of 
swallowing, the velum palati rises and thereby 
draws the anterior wall of the Eustachian tube 
from the i30sterior. At this moment the faucial 
extremity of the tube is so patulous that air 
forced through the nares, not being able to 
l^ass downward into the fauces and mouth, 
because the velum palati prevents it, will by 
following the course of least resistance pass 
into the tube and usually into the tympana. 

In order to accomplish this result at the 
desired moment, the patient is instructed to 
take a sip of water and retain it in his mouth 
until told to swallow. After the water has 
been thus taken, let the surgeon place the 
curved nose-piece into either nostril and com- 
press the nostril in front of the nose-piece. The usual error is made in 
trying to compress the ala of the nostril down upon the nose-piece. 




Politzer's air-bag for inflating 
the middle ears ; one-third natural 
size. 



INSTRUMENTAL EXAMINATION OF THE EAR. 



87 



Fig. 67, 



This is very painful to the patient, is apt to make him jump, and thus the 
surgeon is defeated. The index-finger should compress the other nostril 
so that no air from the bag shall escajDe outward through the nose. The 
point of the nose-piece should be directed outward against the ala rather 
than inward against the bony septum. If the latter is done, and it 
usually is the mistake of beginners, the septum will be painfully pressed 
if not wounded, and bleeding from the nose may be the very undesirable 
result. 

In using this method of inflation, one ear of the patient may be con- 
nected by the auscultation-tube to the ear of the surgeon ; but this is by 
no means necessary, since, as a rule, when the method is properly carried 
out, a peculiar resistance or recoil ensues in the inflation-bag. which the 
surgeon soon learns to recognize. 

By the very nature of the physiological process called to aid in 
Politzer's method of inflation, consisting in forcing air from the infla- 
tion-bag while the nostrils are compressed during the act of swallow- 
ing, both ears are likely to be inflated at the same time (Fig. 67). 
The fact that one ear cannot be isolated at will during this mode of 
inflation should be borne in mind. If for any reason such isolation on 
the part of either ear should be demanded, the 
surgeon must resort to the catheter. The force 
of the Politzer inflation, however, can in any 
case be augmented on either side by pressing 
the finger firmly into the canal of the ear 
opposite to the one it is specially desired to 
ventilate. By some it is thought that this 
latter modification is aided by holding the head 
over towards the shoulder opposite to the ear 
which is to receive the greater amount of infla- 
tion. As in such a position the ear on the up- 
turned side is highest, the supi)osition is that 
the air may take its course more readily to- 
wards that ear than the one turned downward 
and firmly stopped by the finger. Instead of 
swallowing water to insure the elevation of the 
palate, the surgeon may command the patient 

to say ^'hick- or ''hack" (Gruber), or ''aa" (Lucae), or the patient may 
simply distend his cheeks with closed lips (E. E. Holt), thus forcing the 
root and dorsum of the tongue against the velum. 

Inflation by Politzer' s air-bag, like inflation of the tympana by the 
Eustachian catheter, must be used with the greatest caution. It is rarely 
needed as a therajyeutic means, and should never be applied except by an 
expert. 




Inflation of the tympana by Po- 
litzer' s air-bag. 



CHAPTEE YIIL 

TESTS OF HEAEING. 

Aerial and Bone- Conduction of Sound. — Sound is normally conveyed to 
the auditory nerve by the passage of sound-waves into the external audi- 
tory canal, and by the oscillations of the menibrana tympani and ossicles 
which these sonorous waves produce. Sound may also be conveyed to 
the auditory nerve by the vibrations it produces in the osseous tissues of 
the head ; the waves of sound, in the latter instance, being conveyed 
directly to the walls of the labyrinth, and thence to the terminal fila- 
ments of the acoustic ner^^e. The former mode of conveyance of sound 
is called aerial, and the latter mode, bone-conduction of sound. In bone- 
conduction it is probable that some of the waves of sound falling on the 
ossicles set them in motion, and thus some of the sound is conveyed to 
the perceptive apparatus in the labyrinth. 

Normal Searing. — Xo precise standard of normal hearing has ever 
been defined. The normal ear hears all sounds that fall on it ; but it can- 
not be said, a priori^ where good hearing ceases and defective hearing 
begins, for in many senses these are relative terms. 

The sense of hearing must be regarded as composite, — i.e.^ it consists 
in the ability to hear a number of different sounds both periodic and 
irregular in their vibrations. Such sounds can be heard singly or to- 
gether. Hence the sense of hearing may be said to lie in a collection of 
nervous elements which can be aroused separately or together. The 
latter is shown by the well-known fact that more than one sound can be 
heard at the same time. 

The Watch. — Some form of watch-work or ticking apparatus is an old 
and ready means of testing the hearing. In this way the pocket watch, 
mantel clock, metronome, or an especially contrived ticking machine has 
been called into requisition. But the watch being a low form of musical 
instrument, at best giving forth only two poor notes, not easily determi- 
nable in pitch, can never have a wide application as a test. When using 
a watch as a means of determining the hearing, the test is being accom- 
plished with only one or at most two notes. Now, if a defect in the con- 
ducting or in the perceptive auditory a^Dparatus interfere with hearing 
notes given out by the test in a particular case, the watch will not be 
heard, or but imperfectly, whereas a watch the notes of which are of 
a different pitch might be heard. Hence it is that the watch as a test so 
often fails. 

The simplest and most convenient form of watch-test is the ordinary 



TESTS OF HEARING. 89 

pocket timepiece. When using it as a means of testing the hearing, the 

watch should be brought from a point where it is not heard, gradually 

towards the ear, until the ticking is perceived by the patient, or until 

positive inability to hear it, even on contact with the head, is discovered. 

The distance at which the watch used is heard by the normal ear 

should be known by the examiner. This distance may represent the 

denominator of a fractional form of expressing the hearing power ; the 

numerator, the distance heard in a given case. Thus, a watch is heard by 

the normal ear sixty inches and by a diseased ear in a given case twenty 

inches. The record in such a case would be expressed by the fractional 

20 
formula — inches. (J. S. Prout. ) 

The Stop- Watch. — Of all forms of watch-work for testing the hearing, 
the most useful is the stoi^-watch. Besides its x>ower as a test, there is 
also in it the means of finding out whether the patient really hears the 
sound of the watch, or whether he thinlcs he does because he knows a 
watch is being held before his ear. This means is often the first to detect 
the uureliableness of the patient's statements respecting his subjective 
impressions of sound. 

If the ticking of the watch can be alternately stopped and set going 
at the will of the surgeon, errors of obser^^ation on the part of the 
patient may be detected. The same end has been gained by alternately 
holding and removing a diaphragm of paper between the ear and the 
watch. 

In some cases, even while the ticking continues, the patient will state 
that he no longer hears the sound of the watcli. This may be a perfectly 
true statement, and is explained by the fatigue of the diseased ear. As 
will be shown later, some ears affected by clironic aural catarrh manifest 
this tendency to grow fatigued and to cease to hear a sound while listen- 
ing attentively to it. 

As a test for bone-conduction, the watch is limited both by the age of 
a patient and by the weakness of its impact. The latter may be over- 
come by having the ticking apparatus so constructed as to give its sounds 
with great intensity. 

TJie Tuning-Forl'.—Theve are several forms of tuning-fork used in 
making tests of the hearing. The best results are obtained with a large 
instrument giving a powerful fundamental note. 

An instrument which has given satisfaction, and which can be sup- 
plied at moderate cost, is the clinical tuning-fork (Fig. 68). The in- 
strument is set in vibration by gently tapping it against any firm object, 
at one of the short stems on the clamp. 

While the force thus applied is not always the same, practice will 
enable the surgeon to apply nearly the same amount of force in every 
case. The instrument possesses the advantage of great convenience and 
simplicity ; it is twenty-six centimetres long, and gives out a full, deep 



90 



DISEASES OF THE EAR. 



Fig. 



note, free from discordant overtones, when the clamps are properly ad- 
justed at the points. By altering the position of the clamps the funda- 
mental note is changed. 

Politzer^ has devised an acoumeter, consisting of a 
hard-rubber tube four centimetres in length, in which is 
a steel cylinder twenty-eight millimetres long and four 
millimetres in diameter. Above the latter is a small 
hammer, which is made to strike the steel rod by touch- 
ing a spring. There is attached to one side of this in- 
strument a small pedestal, which supports the acoumeter 
against the head when it is desired to test the perceptive 
power of the auditory nerve through the bones of the 
cranium. All these instruments are said to be made 
alike, and are attuned to the note o!'. The inventor 
claims for this instrument the advantage of supplying a 
standard unit of measurement of hearing. 

The Use of the Tuning-Fork in Diagnosis. — The tuning- 
fork is used in two ways, as a test of hearing and as an 
aid in diagnosis : 1. By aerial conduction of its vibra- 
tions, in which instance, the instrument being held near 
the ear, its sound reaches the conducting apparatus in the 
most favorable way, — viz., through the air. 2. By bone- 
conduction, as it is termed, in which the vibrations of 
the tuning-fork are communicated chiefly directly through 
the tissues of the face and cranium to the conducting ap- 
paratus and also to the perceptive organs. The normal 
ear, in a normal skull, is always possessed, at the same 
time, of these two ways of sound-conduction to the auditory nerve ; but 
the normal ear is not conscious of this ability to hear by bone-conduction, 
because it perceives sound so much better by aerial conduction than it can 
through the bones of the head. Therefore, it is not until the normal or 
aerial mode of sound-conduction is interfered with by obstructive disease 
in the sound- conductors that the ear, in its abnormal state, becomes con- 
scious of the conduction of sound through the tissues of the head. This is 
especially marked when the vibrations of sound are communicated directly 
to the bones of the cranium by placing the handle of the vibrating 
tuning-fork upon the vertex, or glabella. Then, if aerial conduction is 
obstructed, the auditory nerve still retaining its function, the affected ear 
becomes conscious of a loud volume of sound from the tuning-fork 
vibrating on the vertex, or glabella. These phenomena are, however, only 
those of modified sound-conduction, and from them can be drawn, for the 
most part, conclusions respecting only the condition of the conducting 
apparatus of the ear. 



Clinical tuning-fork. 



K. K. Gesellschaft der Aerzte, Wien, March 2, 1877. 



TESTS OF HEARING. 91 

Age does not seem to have much to do with the ability to hear by 
bone -conduction, i:)rovided that the fork used is powerful. If the audi- 
tory nerve perceives at all, individuals over eighty years of age usually 
hear the fork vibrating on the vertex ; but doubtless it requires i)Owerful 
vibrations to make themselves felt through the head-bones of the aged. 
A\Tien bone- conduction in the aged seems to be impaired, it is due iDrob- 
ably, as ]Moos has suggested, to a diminished sensibility of the auditory 
nerve. Then, too, the musical education or sense of the patient, as well as 
the perceptive powers, must be taken into consideration ; otherwise hear- 
ing will often be confounded with feeling. It has been found that deaf- 
mutes might, to some, appear to hear the tuning-fork vibrating on the 
vertex, were it not known that what they perceive in such conditions are 
vibrations at the diai^hragm. 

Tuning-ForJ: vibrating on a Farietal Frotiiberance in a Xornial Case. — If 
a vibrating tuning-fork be placed on either parietal protuberance of a 
person with normal hearing, it will be heard in the opiiosite ear. This 
is most easily i)erceived when a large and powerful tuning-fork of low 
note is used. This phenomenon, if it may be so termed, will often lead 
to confusion in diagnosis, inasmuch as the examiner would expect the fork 
to be heard better in the ear nearest to it. As it is heard better in the 
more distant organ, a conclusion might be reached that the latter is dis- 
eased in its conducting parts. This may be due to the fact that vibrations 
which fall perpendicularly on the membrana tympani produce the strong- 
est vibrations, and hence a tuning-fork placed on the parietal protuber- 
ance, or on the side of the head, will be heard chiefly in the opposite 
ear. This is very distinctly perceived if both meatuses are stopped, but 
it is equally perceptible, as any one can find out by exiDerimenting upon 
himself, with the meatus oi^en. Care must, therefore, be taken to have 
the vibrating instrument in the central line of the head, either on the 
vertex or glabella, or held in or on the teeth. 

The tuning-fork finds its greatest usefulness in testing by bone-conduc- 
tion. While it has never fully realized in this way all that was hoped for 
it as an aid in diagnosis, it is still the best means, and a very good one, 
too, of determining how much sound is perceived by the auditory nerve 
through the bones of the head. 

Its musical nature, as well as its powerful vibrations, renders it far 
superior to the watch as a test for the conducting power of the bones of 
the head, unless the ticking of the watch be made to occur with great 
force. But should the ticking of the watch equal in intensity the vibra- 
tions of the tuning-fork, the former could never approach the latter in 
musicalness. 

The tuning-fork is a means of comparison between bone-conduction 
and aerial conduction of sound in the same person ; for, if the vibrating 
tuning-fork be held on the vertex until its note is no longer perceived by 
the examined, and then held before his ear, if he now i3erceive that the 



92 DISEASES OF THE EAR. 

tuning-fork is still vibrating, it is fair to conclude that the sound-conduct- 
ing apparatus is normal. But, if the fork, when no longer heard through 
the air beside the ear, be heard without being restruck as soon as it 
touches the vertex, the conclusion is inevitable that there is some impedi- 
ment in the sound-conducting part of the ear. This is all the more con- 
vincing if it be borne in mind that the same note is being used, and 
one, too, growing a little weaker all the time. For, if vibrations of a 
tuning-fork cease to be heard in front of an ear, by aerial conduction, 
but are able to communicate themselves, while growing constantly weaker, 
through the bones of the head, the inference of great derangement in the 
middle or external ear cannot be avoided. Rlnne' s test consists in apply- 
ing the tuning-fork alternately to the ear and its mastoid process, under 
the above-named conditions. 

Speech. — By hearing speech the intellectual development of the human 
being is accomplished. All aurists are aware that patients are constantly 
sur^Drised to learn the amount of their deafness as soon as their faces are 
turned from the speaker. The failure in hearing in this respect is often 
first detected by the patient in the summer-time, when all are accustomed 
to sit on x)orches or in the parlor, in twilight and the dark. As the day- 
light fades and the faces of those around are no longer plainly visible, 
the hitherto apparently hearing person becomes aware that he is growing 
deaf. This is often assigned to the night air, but in reality it is due to 
the loss of vision in the darkness. The surgeon will often derive great 
aid from a knowledge of these facts, and also by observing how a partially 
deaf patient will look at the person speaking. 

The human ear perceives, as music, tones varying from sixteen vibra- 
tions to twenty thousand vibrations in a second. Preyer has lately placed 
these limits from fifteen vibrations to forty thousand nine hundred and 
sixty vibrations in a second. Blake has shown that in some instances the 
human ear distinctly hears, as musical tones, from thirty-five thousand to 
forty thousand nine hundred and sixty vibrations in a second. 

Speech, according to O. Wolf, embraces only eight octaves, — viz., R 
of sixteen vibrations, and S of four thousand three hundred and twenty- 
four vibrations in a second. It may be said, therefore, to lie entirely 
within the limits of music. 

Acoustic Character of Yotvels and Consonants. — The distance at which 
separate voiveJs can be heard has not yet been established, but they are 
endowed with the greatest strength of tone, being heard and understood 
at a distance at which all the consonants are inaudible. 

Consonants. — Consonants may be classified, according to their acoustic 
and physiological laws, under two heads, — viz., those which are self- 
sounding and those which are sound-borrowing. The former are such as 
possess a sound entirely independent of association with a vowel sound, 
and one that can be defined respecting its pitch, intensity, and timbre. 
The latter are such as must be either preceded or followed by a vowel in 



TESTS OF HEARING. 93 

order to render them audible, and hence the name of sound-borrowing 
consonants has been api^lied to them by Wolf. 

Helmholtz has also pointed out the very noticeable fact that if in calm 
weather an observer be placed on some elevation near a town, — a tower 
or a hill- top, — it will be found that words are no longer distinguishable, 
or at best only those composed of M and X with vowels. Yowels can be 
heard following one another in a curious mixture, and with remarkable 
cadences, because no consonants are heard, and the other vocal sounds 
cannot be joined into words. ^ 

It is thus shown that in the component sounds of speech a wide range 
of tests of different intensities and pitch is offered to the aurist. Such a 
numerous set of tests is needed in order to discover which sounds are 
heard best by an affected ear. One sound is not sufficient, because an 
ear may be unable to hear certain sounds, but be comparatively good for 
others. Hence, if only one or two sounds should be employed, as in the 
watch, just those sounds might not be heard as well as others. Xo 
sound-unit has ever been established, and, if it were, it would be useless, 
since, from the nature of the ear, such a unit would not be equally appli- 
cable in all cases. Therefore speech becomes valuable as a test because 
of its composite sound-nature, and also because it is ever at the command 
of the examiner, whose object in applying it as a test is comprehended 
by the patient without any preliminary instruction. 

Whispering and Loud Tones. — Very often whispers and words spoken 
in low tones are heard much more distinctly hx the affected ear than 
loudly spoken words. This is due to the damping of vowels, as shown by 
Wolf, whereby the consonants, which have been stated to be less sonorous 
than vowels, have a chance to be heard. This fact is of great impor- 
tance, not only in estimating the hearing, but in adelressing those hard 
of hearing. Members of a family very often j)itch their voices too high, 
and hence confuse the afflicted one, thus gaining the idea that the indi- 
vidual is deafer than he really is. On the other hand, they are sur^Drised 
that on some occasions he hears sounds and words spoken to others in 
comparatively low tones. Do not elevate the voice too high when you 
wish to make a deaf j)erson hear, but do not lower it too much, unless to 
a whisper, if it is not desired that he should hear. 

Whispering. — Whispering has an advantage over loud words in test- 
ing, since the former caimot be as easily conveyed as the latter through 
the bones of the head to the auditory nerve. 

Variable Searing. — The hearing varies very greatlj" in cases of movable 
fluid in the tympanic cavity and in some forms of aural vertigo. When 
such peculiarities of hearing are fully established, they may aid greatly 
iu diagnosis. The first kind is made manifest by changes of position of 
the patient's head ; the second form of variability of hearing comes and 

^ Tonempfindungen, etc., S. 118. 



94 DISEASES OF THE EAR. 

goes with the paroxysm of vertigo. It is probably due to alterations in 
the condition of the muscles in the tympanum, whereby altered tension 
in the sound-conducting apparatus is produced. 

Searing Low Tones better than Sigh Ones. — It is sometimes observed 
by patients that they hear low, bass notes much better than high ones -, 
as, for example, in two instances patients volunteered the information 
that they heard thunder much better than the chirping of crickets, and 
bass notes much better than high ones on the piano or organ. In testing 
with a watch, it was found that one giving out the deeper note was most 
easily heard by one of these patients ; the other was not thus tested. 
Experimentally, I have shown that a deep note has the advantage of high 
notes in cases of increased labyrinthine pressure (page 45). In an increase 
of such pressure the stapes becomes more fixed, and it is on this small 
bone that the vibrations begin to grow less as the i^ressure within the 
labyrinth is increased. In such a case it is manifest that, if vibrations 
from without are normally conveyed to the stapes, they must there meet 
with hinderance in their endeavor to reach the labyrinth. Only the more 
powerful sound-waves are able to overcome this obstacle and force the 
stapes into to-and-fro motions with the rest of the chain of ossicles. 

The position and extent of perforation in the menibrana tympani may 
cause variation in the hearing-power for certain sounds, especially con- 
sonants, as shown by \Yolf.^ Experiments with the consonant B upon 
defective drum -heads show that the perceptive power for this sound 
diminishes as the extent of the defect increases. The faintness of the 
consonant is most observable when it stands at the end of the word. It 
may also be said that defects of the membrana flaccida are attended by 
great deafness for all sounds, which is probably due to an implication of 
the malleo-incudal joint. 

Testing the Searing in One-sided Deafness. — In measuring the hearing 
for sounds conveyed through the air in cases of one-sided deafness, or of 
hardness of hearing confined chiefly, if not entirely, to one ear, care 
must be taken not to attribute to the worse ear that w^hich is really heard 
by the better ear, though stopped and turned from the examiner. In 
any case where one ear is being tested, accuracy would demand the isola- 
tion of the other. Usually, the ear not being tested is stopped and turned 
from the source of sound, the ear under examination being left open and 
turned towards the sound source. This method will usually give at least 
a proximate result as to the amount of hearing in the worse ear ; but in 
order to exclude the fact that the better ear, though stopped and turned 
away, hears some of this test, it will be necessary to measure the hearing 
in the worse ear alternately open and stopped in order to see what effect 
this stoppage will have upon the amount of hearing it is supposed the 
worse ear still retains. 

^ Sprache und Ohr, second part. 



TESTS OF HEARING. 95 

Acoustic Bailroad Signals. — At the time of entering the service loco- 
motive engineers and stokers should have, at least on one side, normal 
hearing or nearly so. Every two to five years these operatives should be 
re-examined and their hearing distance tested with a continuous scale, 
to see whether the required signals are properly heard. Operatives in 
the service of railroads should be able to hear a whisper at a distance 
of at least one metre, or a yard. 

Simulated Deafness. — ^Minute acquaintance with otologic diagnosis 
ranks above all other means for the detection of aural malingering. 

Cutaneous diseases, organic defects, morbid growths, and injuries of 
the auricle enter so largely into the work of the dermatologist and the 
general surgeon, and so little into the work of the aurist, that they will 
not be considered in this treatise, excepting in so far as they aifect the ex- 
ternal auditory canal, impair the hearing, and are thus brought to the 
aurist' s attention. 



CHAPTEE IX. 

CIKCUMSCRIBED AND DIFFUSE INFLAMMATION OF THE EXTERNAL 

AUDITORY CANAL. 

OTITIS EXTERNA CIRCUMSCRIPTA. 

Otitis externa circumscripta consists in a circnmscribed inflam- 
mation of the skin or subcutaneous cellular and fibrous tissues of tlie 
auditory canal, terminating in a small abscess or boil, which, in dis- 
charging its contents, produces considerable destruction of the skin 
covering it. Its seat is not confined to any particular portion of the 
auditory canal, but as it is most likely to occur in a region rich in glands, 
it is apt to be found in the outer part of the meatus. 

Symptoms. — This disease is usually extremely painful, and is attended 
by fever and even considerable cerebral symptoms in some cases. The 
boils usually occur one at a time, but the series may amount to a dozen. 
Sometimes they ai)pear to merge so fast into one another that the ease 
gained by the discharge of one is hardly enjoyed by the victim until the 
throbbing and burning pain of a new one warns him that he must endure 
the torment of another. The auricle may become sensitive to the least 
touch and traction, especially if the abscesses are in the cartilaginous 
part of the canal, and the patient then cannot endure the ordinary 
pressure of the affected side of the head on the pillow. But such sensi- 
tiveness of the ear is not so likely to occur in this form of otitis externa 
as in the diffuse form. The severest pain and most distressing symptoms 
are found when the boil is seated in the unpliable parts of the bony 
portion of the canal ; intense distress, however, may be caused by a boil 
seated just within the opening of the auditory canal. tJsually the 
gravity of the pain and febrile symptoms will depend upon the depth 
of the abscess in the tissues of the auditory canal, as well as upon its 
proximity to the drum-head. Small superficial abscesses do occur in the 
meatus without any pain, a sense of discomfort and dulness of hearing 
having been the only cause of the patient's seeking surgical relief. 
But, of course, such cases are very rare, and are explained by the 
superficial seat of the inflammation. Hardness of hearing and deafness 
are prominent symptoms of furuncles in the auditory canal. In some 
cases the deafness is almost absolute, and the congestion being so great, 
and extending consecutively even into the cavity of the tympanum, the 
deafness is the last symptom to disappear. But the patient can be 
assured of the ultimate return of the hearing in such cases if there has 
been no organic lesion of the drum- cavity. 

96 



INFLAMMATIOX OF THE EXTERNAL AUDITORY CAXAL. 97 

Inspection of the auditory canal and membrana tympani is usually 
very difficult if the disease is advanced and the swelling of the meatus 
considerable. This difficulty is less likely to occur when the disease is 
in the outer part of the cartilaginous portion of the auditory canal, for 
with care it may gradually be stretched by the speculum. When the 
abscess is in the inner portion of the cartilaginous canal, one can usually 
obtain a view of the drum-head only in the earlier stages of the disease. 
When the abscess in the deeper portion of the canal becomes fully de- 
veloped, the view of the drum-head will be entirely cut off and the deaf- 
ness and tinnitus become great. After the discharge has occurred the 
drum-head may be seen as a red and somew^hat sodden membrane, which, 
however, in a few days gradually assumes its normal color and outline, 
and the hearing will be found to be returning. 

Etiology. — Boils in the external auditory canal are always of artificial 
origin, being caused by the insertion of septic matter into a follicle 
of the skin in the act of rubbing or scratching of these parts by the 
patient. 

Treatment. — The treatment of a boil in its immature stage should con- 
sist in the application of a pledget of cotton soaked in a mixture of 
black wash and gij'cerin (one part of the latter to seven of the former). 
This softens the inflamed tissues with an antiseptic dressing. The latter 
should be renewed every hour or two until maturation of the boil. As 
soon as the latter occurs the surgeon should mop away with a formalin 
solution (1 to 1000) all results of inflammation, and then mop the open 
mouth of the boil with ichthyol and water in equal parts. If some ich- 
thyol can be forced into the abscess cavity it will be an advantage. 
Under this treatment I have rarely seen a second boil spring uj) in the 
ear, whereas the old method of septic i^oulticing was always followed by 
a crop of boils. Neither should a boil be incised, as the cut furnishes a 
furrow for the staphylococcus to grow in and produce more boils or even 
a diffuse otitis externa or dermatitis in the canal. 

DIFFUSE OTITIS EXTERNA. 

Diffuse otitis externa consists in a general dermatitis of the external 
auditory canal. It is characterized by redness, swelling, and sensitive- 
ness of the entire external auditory canal, and in some cases by similar 
symptoms in the concha. In such a condition the patient cannot endure 
touching or moving the auricle. 

Etiology. — The causes of difi'use otitis externa are various forms of 
irritants applied to the skin of the external auditory canal. These may 
come from within or without. Among the latter may be named exposure 
to cold air and cold water, traumatism of any kind, furunculosis of the 
external meatus, and the extension of skin diseases from the face and 
auricle to the auditory canal. The imj)roper use of all kinds of ear- 
picks, aurilaves, hairpins, and toothpicks for fancied cleansing or for 



98 DISEASES OF THE EAR. 

« scratching the ear- canal is constantly productive of diffuse external 
otitis. 

Sypliilitic Otitis Externa. — Soft chancres and mucous patches have been 
observed in the external auditory canal. I have seen in secondary syphi- 
lis, when an erythema was visible upon the forehead and face of the 
patient, a similar papular and furfuraceous condition of the auditory 
canal and membrana tympani. Under constitutional treatment the erup- 
tion disappeared simultaneously from all the affected parts. I have also 
seen in several instances cicatrices after ulceration of the canal and 
membrana tympani in adults who had been the subjects of hereditary 
syphilis. 

The diphtheritic form of diffuse external otitis is very rare, being un- 
mentioned by many authorities. According to the best observers, it is 
never a primary affection, but rather an occurrence in the later stages of 
an inflammatory process. This form of the disease is usually found in 
scrofulous subjects in whom the original inflammation has been either 
neglected or imx)roperly treated. In all such cases, after the usual puru- 
lent discharge has lasted a longer or shorter time, there is a sudden in- 
crease of pain and fever, with the simultaneous appearance of a white 
diphtheritic membrane, which adheres most closely to the inflamed struc- 
ture, and when even lightly touched causes intense pain and some bleeding 
of the parts beneath. 

In children there is often found, at the termination of an attack of 
diphtheria, inflammation in the external ear. This rapidly extends, 
in some cases, directly to the bone of the canal and backward to the 
mastoid process. Pain is not a prominent symptom in these inflamma- 
tions following diphtheria, and this fact will readily distinguish them 
from the truly diphtheritic form of external otitis in which the peculiar 
false membrane is found in the auditory canal. The form of the disease 
now referred to is one arising from the broken-down condition of the little 
patient rather than a form of disease already described as the diphtheritic. 
In the former case the pain is not great, the swelling is considerable, and 
the tendency to attack the bone is marked. Fluctuation is soon felt over 
the mastoid region, and after the evacuation of the pus the bone beneath 
is found denuded and in some cases crumbling. Exuberant granulations 
spring up around the opening inade by the knife in the soft parts, and 
the peculiar depressed mouth of a sinus leading to dead bone soon begins 
to make its appearance. With a probe, a tract of bare bone correspond- 
ing to the region around the bony meatus may be detected. For weeks 
no portions of this diseased bone will come away, but at last the nearest 
edge of the dead tract will appear to rise up, so that a probe may be 
worked under it, and then gradually, day by day, the dead shell or scale 
of bone (for it is in many cases the outer wall of the mastoid cells) will 
be found to be coming out through the sinus. This process is attended 
by more or less discharge from the ear, but if the sinus behind the ear 



INFLAMMATION OF THE EXTERNAL AUDITORY CANAL. , 99 

is kept freely open, the discharge from the auditory canal will be very 
slight, and hence granulations are not usually found in the canal in such a 
case, for the drainage is kept u]3 from behind and away from the auditory 
meatus. During this process the patient has no pain and the discharge 
is not very copious, but there will be, from time to time, swelling of the 
glands in front of and under the ear and down the tract of the sterno-cleido- 
mastoid muscle. These swellings are neither painful nor very hard. They 
last for a few days and then usually disappear, though they may suppurate 
in the worst cases. 

In badly fed and delicate children the diphtheritic form of otitis ex- 
terna may pass into the gangreiwus variety. According to Gruber, otitis 
gaugraenosa is much more likely to occur in children than in adults. 
Although the external otitis occurring in diphtheritic children may lead 
to necrosis in and about the tympanum, with exfoliation of large i:)ieces 
of the posterior wall of the auditory canal, I have never seen such cases 
assume a truly gangrenous nature. 

Diagnosis. — The prominent symptoms of otitis externa diffusa are the 
great pain and the high degree of hardness of hearing and tinnitus as the 
swelling in the canal increases. The motions of the jaw also cause great 
pain, and the patient is unwilling to chew hard substances on account 
of the tenderness of the ear. Inspection of the membrana is cut off by 
the swollen walls and consequent obstruction of the auditory canal. 

Treatment. — If we are able to begin the treatment of diffuse inflam- 
mation of the external auditory canal in the early stages of congestion 
and pain, the first coarse to ]3ursue will be to cleanse the auditory canal 
by syringing with carbolic acid and warm water (1 to 40), and then apply 
black wash on cotton. If the skin begins to secrete, as it may at more 
than one j)oint, there should be applied to the canal equal parts of ich- 
thyol and water either by gentle mopping or on cotton wicks kept in the 
canal for from twelve to twenty-four hours, when these dressings should 
be removed and fresh ones put in by the surgeon. There can be no suc- 
cessful antiseptic treatment of an acute ear disease of any kind by the 
patient or his friends at home, ^^en discharge has been fully estab- 
lished, nothing will be found as efficient in checking it and in preventing 
the growth of granulations as insufflation of boric acid in fine powder, 
europhen, or nosophen. 

If polypi should spring up with well-defined base or pedicle, they 
must be extracted hj one of the various means described farther on, and 
their attachment to the canal thoroughly touched with a saturated so- 
lution of silver nitrate or a very minute quantity of chromic acid. In 
every case where polypi are pulled out the patient should be told before 
the extraction that it will be necessary to touch the base of the growth 
with the acid or some other caustic several times, perhaps, in order to 
effect a cure. 

The treatment just described is that adapted to the ordinary form of 



100 DISEASES OF THE EAR. 

otitis externa diffusa with no worse complication than polypoid granula- 
tions or polypi ; there are, however, several other forms of this disease, as 
already stated, — viz., the diphtheritic, the gangrenous, the syphilitic, and 
the parasitic. 

The treatment will be modified in the first three by the fact that they 
are much more painful than the fourth, which, however, causes some 
pain. As the first three indicate a constitutional alteration and poison- 
ing of the blood, their treatment must be largely of a supporting and 
alterative nature. Their names will indicate the kind of blood-poisoning 
they are due to, and their general treatment must be conducted on the 
principles followed in the same diseases when they manifest themselves 
elsewhere in the body. 

Otomycosis. — The most common cause of this form of otitis externa dif- 
fusa is the growth in the auditory canal of that kind of fungus called 
Aspergillus. Its two chief varieties are A. nigricans and A. glaucus, or 
flavescens, the former of which is found in the ear much more frequently 
than the latter. The ascomycete, or the highest form of development of 
the aspergillus, is of very rare occurrence in the ear. Some writers al- 
lude to an A. flavescens, but this is probably only a darker- colored A. 
glaucus. Clinically, it would be much better to call the A. nigricans the 
A. major, and A. glaucus the A. minor, since the former is so much larger 
than the latter. This difference in size, as well as in other ways, is 
easily seen under the microscope. Macroscopically, there is no distinct 
and guiding difference in appearance between these two forms of the 
fungus. The microscope alone can decide which of the two forms we 
are dealing with in a diseased ear. 

These forms are easily distinguished from each other by the shape 
of their fruit-heads and the arrangement of the sterigmata thereon, 
and on these differences I propose to base their nomenclature. So far 
as their color is concerned, it is wholly unreliable as a diagnostic differ- 
ence ; in no instance is it either clearly green or black. In all cases of 
ordinary aspergillus the color is yellowish or brownish. It has never 
been shown that one form excites an inflammation different from that 
produced by the other. For the sake of uniformity and order, I shall 
retain the names A. nigricans for the larger and A. glaucus for the smaller 
species. 

Microscopic Features. — The microscopic features of the growth of this 
parasite in the human ear are varied and full of interest. If a small 
piece of a colony of Aspergillus nigricans, in the earliest stages of its de- 
velopment, be examined under the microscope with a power varying from 
two hundred and fifty to three hundred diameters, a field similar to that 
in Fig. 69 will be observed. It is, in fact, the first formation of rootlets 
or the mycelial web, from which, at a later period, the fruit-stalks or 
fructiferous hyphens spring. It will also be seen that some of the fila- 
ments composing the web tend to become bulbous at one end, and that 



INFLAMMATION OF THE EXTERNAL AUDITORY CANAL. 



101 



the latter, as the stem grows, becomes larger and dotted (Fig. 70), until 
finally there is standing out from the dense web of mycelial filaments a 
perfect fruit- stalk and a fructiferous head, — 
the latter studded with short, peg-like limbs, 
the sterigmata, on the free ends of which 
are the spores (Fig. 71, B). All of these 
stages of growth I have watched in speci- 
mens of the fungus removed from the human 
ear. In the fluid parts of the specimen epi- 
thelium may usually be seen in small quan- 
tities as the parasite develops, as in the 
upper part of Fig. 70. ^ 

Yery rapidly — in the course of a day or 
two at most — the perfect fruit-stalk is formed 
in large numbers and in all stages of devel- 
opment, and the mycelial filaments can be 

seen to be coarser and septate. On one hand is a well- formed though un- 
ripe fruit-stalk and head (Fig. 71, B), while in the centre of the field there 
may be seen the ripe aerial fruit, from which the fully grown spores drop 
literally in myriads (Fig. 71, C). 




Fig. 70. 



Fig. 71. 





The characteristic difference between the two varieties of aspergillus, 
the so-called yelloiv and blacl', is seen in the shape and size of the recep- 
tacidum and the arrangement of the sterigmata upon it, these two parts 
forming the so-called head or sporangium. 

In the A. nigricans (Fig. 71, B) the sporangia or heads are distin- 
guished from those of the A. glaucus (Fig. 71, A) by the fact that in the first 
the sterigmata cover the receptaculum, which is spherical, on all sides, 
while in the latter, the lower fifth or fourth of the receptaculum, which 
is ovoid in shape, is entirely free from sporangia. 

2Iacroscopic Features. — The macroscopic appearances of a mass of this 



Figs. 



70, and 71 are from original drawings by the author. 



102 DISEASES OF THE EAR. 

fungus, as found in or washed from the ear, are worthy of attention. If 
an ear containing a mass of aspergillus be examined by means of an ear- 
mirror and ear- funnel, it will present most usually an appearance which 
leads to the supposition that the ear is occluded not by wax, but by a 
foreign matter of an organic nature. 

If the fungus has been in the ear but a short time, merely a patch of 
pale yellow, pollen-like matter, of varying diameters, will be detected at 
the fundus of the auditory canal. This small colony of si)ores just devel- 
oping into filaments is usually situate on the membrana tympani or very 
near it. In any case, whether or not the first deposition of spores occurs 
there, the tendency of the aspergillus is to grow over the drum-head 
first, and from that point it spreads outward, covering the wall of the 
meatus, until a hollow cast of the canal is formed by the vegetable para- 
site. The iDollen-like appearance is seen only in the very earliest stages of 
the growth of that which finally becomes so-called lardaceous-looking false 
membrane, either partially or entirely filling the external auditory canal. 

In some cases the fungous mass looks like a ball or plug of wet news- 
paper, and in others the ear may seem to be jDlugged with a substance 
looking like wool. An inexperienced eye might conclude that the oc- 
cluding plug thus formed is of ear-wax ; but ear-wax looks more solid, 
shining, and drier, and never excites pain and inflammation in the ear 
like the fungus aspergillus. 

This false membrane is composed chiefly of mycelial net- work, with 
all forms of aerial fructiflcation of the plant, and some epithelium from 
the auditory canal. The sporangia are usually found on the surface of 
the false membrane turned towards the wall of the auditory canal. Al- 
though the most perfect forms of growth of the fungus are usually found 
near the drum- membrane, I have seen si^ecimens so flourishing at the 
mouth of the auditory canal that the latter appeared to be sprinkled 
with bright yellow pollen. In such a case the membrana tympani may 
not be seriously implicated. Usually, however, the membrana tympani 
and the skin of the canal near it are inflamed by the aspergillus. 

An auditory canal which has been the seat of inflammation is most 
liable to be invaded by the aspergillus. It seems that the remnants of 
the inflammatory disease, such as pus, dried mucus, epithelial debris^ or 
blood, form excellent soil for the growth of the parasite. An active dis- 
charge from the ear, however, is unfavorable to the growth of asiDcrgillus in 
the canal. Aspergillus cannot remain in an auditory canal for any length 
of time without causing the characteristic symptoms of its presence. 

Symptoms. — The symptoms of this disease are a sense of fulness, slight 
pain, burning, itching, tinnitus aurium, and hardness of hearing. The 
vessels of the malleus become congested, and in a day or two the mem- 
brana tympani is hidden by a thick, white, false membrane. The 
slight serous discharge which now sets in marks the detachment of the 
false membrane and the cessation of pain. In some cases the cutis of the 



INFLAMMATION OF THE EXTERNAL AUDITORY CANAL. 103 

auditory canal is deeply inflamed, but not invariably. The pain may 
become intense if tlie parasite is not removed. Men are more fre- 
quently attacked than women. Aspergillus not only spreads from the 
drum-head to the wall of the auditory canal and vice versa, but it some- 
times perforates the drum-head and finds its way into the drum-cavity. 

Etiology. — Eespecting the etiology, it may be stated that previous dis- 
ease of the ear, esj)ec1ally when limited to the canal, and the use of septic 
domestic remedies for different aural diseases are the most fruitful causes 
of this malady. 

Treatment. — The treatment of otomycosis of the fundus and walls of 
the external auditory canal, induced by the growth of aspergillus, con- 
sists first in removing the parasite, and, secondly, in destroying the germs 
and allaying the inflammation which their growth in the ear-canal has 
caused. The destruction of the parasite is most easily and efficiently ac- 
complished by thoroughly covering the fundus of the canal and all other 
parts of the external ear affected by the growth of the fungus with pow- 
dered boric acid, borax, or boric acid in combination with chinoline 
salicylate (one of the latter to sixteen of the former). Thorough syringing 
on the part of the surgeon will accomplish the removal of all parts of 
the mycelial false membrane which may have become detached from the 
wall of the auditory canal. Those portions of the parasitic growth not 
spontaneously detached can generally be loosened or wiped from their 
seat by means of the gentle use of the cotton dossil on the cotton-holder, 
under thorough illumination of the affected parts by the forehead-mirror. 
The method of application of these, or any i)owders, to the affected ear 
is by insufflation, as represented on page 77. An ear affected with as- 
XDcrgillus should be seen every day by the surgeon, who alone should 
syringe it, and thus remove the loosened portions of the membrane. 
After the ear is thus cleansed, a fi^esh insufflation should be made of one 
of the powders named above. This is hx far the quickest method of 
destroying aspergillus in the ear and of allaying the inflammation it has 
produced. 

The substances named as useful powders doubtless owe their virtue 
to their antiseptic and germicide properties. I have found it useful, after 
all signs of the growth of the parasitic fungus and inflammation have 
disappeared, to allow the powder to remain a little while in the ear — it 
may remain there indefinitely without injury — in order thoroughly 
to sterilize the previously affected parts. 



CHAPTER X. 

FOREIGN BODIES IN THE EXTERNAL EAR. 

Animate as well as inanimate bodies are frequently found in the 
external ear. The former may become of great surgical importance 
from the annoyance, inflammation, pain, and deafness which they are 
very apt to produce, as well as from the fact that they may find their 
way into the middle ear. 

The source of foreign bodies may be either from within or without. 
Under the first class may be placed : abnormal collections of ear-wax 
from the ceruminous glands 5 masses of horny epithelial scales, forming 
the so-called Jceratosis ohturans of Wreden ; and collections of stiff hairs 
from the tragus and auditory canal ; also clotted blood, inspissated aural 
discharges, scales of dead bone, and, in one sense, many of the new 
formations in the external ear. But, of these varieties of foreign bodies, 
only the first three will be considered here ; the remainder are discussed 
elsewhere. 

Under the second head may be classed all animate or inanimate 
things small enough to have been placed in or gotten into the external 
ear from without. 

The manner in which they may get into the ear is extremely varied. 
Foreign bodies of this class are most frequently found in the ears of chil- 
dren, where they are placed, usually in play, by the victim or his com- 
panions 5 or foreign substances may be thrust into the ears of adults and 
of children by accidental or intentional violence. Animate bodies fly or 
crawl into the ear of man. 

FOKEIGN BODIES ORIGINATING IN THE EAR. 

Collections of Cerumeyi in the Ear. — The appearances of an impacted 
plug of cerumen in the external auditory canal are not very varied. 
Usually it is easily recognized, but now and then, especially when the 
impacted mass is due to slow accretion by the daily pushing in and 
smoothing down of its layers by the towel or fingers of the patient, it 
will not be easy for the unpractised eye to recognize the mass at once 
as one of cerumen, for in some cases the impaction has so completely 
adapted itself to the fundus of the meatus and the drum-head as to 
resemble a dark and polished membrana tympani. In many cases such a 
polished mass of cerumen has been regarded as a somewhat abnormally 
colored drum-head, and treated as such, the deafness dependent upon the 
impaction of the wax being attributed to other causes and in some way 
104 



FOREIGN BODIES IX THE EXTERNAL EAR. 105 

connected with the '^discolored membrana tympani." Such failures in 
diagnosis lead to curious results. 

It is, indeed, not uncommon to find patients suffering from impaction 
of cerumen in the auditory canal being treated for some other aural dis- 
ease with which they are not affected. Thus, the Eustachian catheter 
and instillation of silver nitrate have been applied to relieve the deaf- 
ness which a x^roper syringing would have speedilj^ cured. 

\Yhen the onset of hardness of hearing in cases of impacted cerumen 
is rapid, it will usually be found that the mass has been suddenly washed 
in ui:)on the drum-head in bathing. 

When the deafness due to impacted cerumen has been coming on 
slowly for months, sometimes for years, it will usually be found that the pa- 
tient has been addicted to the very bad habit of swabbing out his ears, most 
commonly with the rolled-up corner of a towel, and sometimes with that 
most pernicious and reprehensible implement, a piece of sponge fastened 
to a stick, and sold by druggists under the high-sounding name of an 
'^aurilave." In these cases the plug will be found well packed in and 
moulded to the fundus of the auditory canal and drum-head. 

Such masses are not very hard to remove, considering the long period 
of their accumulation ; they are usually found to contain large quantities 
of short fibres of cotton or linen from the towel used in the efforts to 
cleanse the ear. 

Impaction of cerumen by attempts at cleansing the meatus not only 
occurs among adults, but is found among children, whose over-anxious 
attendants are constantlj^ swabbing out the meatuses of their charges with a 
corner of a towel or by other means. Such treatment sometimes results in 
a chronic ulcer of the bony portion of the auditory canal, or in the growth 
of a large polypus from an ulcerated spot on the wall of the bony canal 
very near the drum-head. 

In these cases of artificially impacted epidermis and cerumen the 
foreign mass usually assumes the form of a hollow cast of the auditory 
canal, or a glove-finger, with a cast of the drum-head on the tip. Such 
cases are usually stubborn, and in some instances the integrity of the bony 
structure of the auditory canal is threatened. 

Beflex Effect of Cerumen Plugs. — Ear-cough, vertigo, and nausea, in 
addition to deafness, may be produced by wax plugs in the ear. Even a 
melancholic form of dysthymia may be caused by such mechanical irri- 
tation in the external ear of nervous patients. 

Treatment. — The treatment of simple impaction of wax in the ear con- 
sists in the use of the syringe, as already explained (pages 81, 82). 

Laminated Epithelial Plug in the External Auditory Canal. — This obstruc- 
tive disease of the external ear was first described by Wreden,^ of St. 
Petersburg, and named by him keratosis obturans, in contradistinction to 

^ Archives of Oph. and Otol., 1874. 



106 DISEASES OF THE EAR. 

ceruminosis obturans, the impacted plug of ear-wax, with which it has 
often been confounded, though differing from it very widely. The latter, 
as its name implies, consists of a mass of inspissated cerumen, but it 
is easily removed by proper syringing, and the ceruminous nature of 
the mass removed from the ear is recognized, among other features, by 
the rapidity with which it dissolves in water. 

Keratosis obturans, however, justly described as a separate and special 
disease of the ear, is a collection of epithelial laminae, derived from the 
cutis of the external auditory canal, of gradual accretion, causing great 
deafness, and very obstinate in its resistance to removal. Beneath these 
masses, in a typical case, the membrana tympani will be found normal 
in appearance and usually unimjDaired in function, but the skin of the 
walls of the auditory canal will be found ulcerated beneath such col- 
lections of epithelium. The hearing, as a rule, is good after the removal 
of the mass of epithelium from the canal. 

These obstructive bodies are not confined to any age or sex. Upon 
inspection of an ear containing such a mass as has been described, a thin 
layer of ordinary cerumen may be seen covering the outer surface of the 
plug, and hence the impression is often arrived at that the case is one of 
ordinary ceruminous impaction ; but continued syringing, by its barren 
results, soon convinces the operator that he has encountered no such 
ordinary obstruction. 

The chronic inflammation and desquamation in the skin of the 
auditory canal usually found in these cases may have been set up and 
favored by the undue efforts at cleansing by the use of a swab, which, 
unfortunately, some individuals expend vc^on themselves and upon those 
under their care. Excoriation is first brought about, and then a slow 
exfoliation of dermoid cells goes on, and these are packed in and me- 
chanically retained in the canal. As the mass of hard epidermis increases 
in size, it presses on the skin of the canal and tends to increase the local 
irritation. So great is the pressure and so sensitive is the inflamed skin 
in many cases of this desquamative affection of the ear that the presence 
of these laminated plugs is often attended by great and constant neu- 
ralgia in the auditory canal, in front of and behind the auricle, and 
even over the temple. These plugs are so hard that they retain any dis- 
charge which may emanate from the inflamed surface. In this way they 
further tend to keep up irritation and pain and to complicate the disease. 

Treatment. — In cases showing a decided tendency to recurrence or 
renewal of these masses in the ear, care in preventing an accumulation 
of the horny laminae, by close watching and speedy removal of the 
slightest amount of scales, will greatly simplify the disease and the 
treatment. 

A solution of soda in water (ten grains to the fluidounce) is the 
simplest and best loosener of the plug from the wall of the canal, but 
sooner or later recourse must be had to forceps and blunt probes. This 



FOREIGN BODIES IX THE EXTERNAL EAR. 107 

disease seems to furnish the exception to the rule of treatment, never to 
use anything more forcible than the stream from the syringe for the re- 
moval of foreign bodies from the ear. Of course, the greatest care must be 
observed in the use of such instruments^ and no one but the most experienced 
surgeon is justified in attempting to remove such a mass by instrumental means. 
Perfect illumination of the meatus by means of the forehead- mirror 
or electric lamp, proper instruments, and cautious movements, added to 
a thorough knowledge of the use of the implements and the part to be 
operated on, must insure success. 

The forceps represented in Fig. 60 (same size as original) is made to 
open and close very gently, and, being slender, cannot take a A'ery firm 
hold upon the impacted mass of keratosis, but it is strong enough to pick 
off and lift away portions of the obstruction. 

I fully agree with those who earnestly deprecate the use of any other 
instrument than a syringe for the removal of foreign bodies from the 
ear. The forceps, or any other instrument for removing objects from the 
ear, must never be tried until all other means have proved of no avail, 
and then only in the hands of the most exi)erienced and under the most 
perfect illumination ; for any manipulation of the ear resembling a blind 
grappling after the foreign body will most surely prove disastrous. Un- 
fortunately, the i^roper occasion for the use of the forceps is almost 
invariably in an emergency, and is performed by the most inexi3erienced 
hands. Moreover, an examination into the facts of the case in which 
they must finally be used will usually reveal that originally they were 
not needed, and that the simplest syringing at the outset would have 
rendered the use of any other instrument unnecessary. 

The only justifiable use of forceps at the outset may be in a case of 
keratosis obturans, but even in such cases all instruments must be used 
with the greatest caution in conjunction with repeated and thorough 
syringing. The accidents happening to the ear from the ignorant use 
of instruments for the removal of foreign bodies have been very nu- 
merous. 

Seborrhea of the External Auditory Canal. — This cutaneous disease is 
sometimes found in the auditory canal. It usually affects both ears at 
the same time, and women are more apt to be the subjects of the disease 
than men. The patients complain of having felt some pain or itching 
in the ear or ears, which has led them to make various applications to 
the affected parts and to scratch the ears with some implement, such 
as a pin. This may lead to inflammation and great pain. They gener- 
ally find, sooner or later, that their ears are full of inspissated matter, in 
crust-like pieces, which they consider dead skin. In consequence of this 
accumulation there are more or less hardness of hearing and tinnitus 
aurium. It is for these last-named sj^mptoms that they seek relief. Upon 
inspection, the surgeon finds the auditory canal filled with graj^ish-white, 
thick scales, more or less united into a pellicle, clinging to the wall of the 



108 DISEASES OF THE EAR. 

canal and extending over the membrana tympani. The caliber of the 
canal may not be entirely filled with this mass^ but the drum-head is cov- 
ered by it. This obstructive matter can generally be removed by for- 
ceps, and, owing to its tough coherence, it may be got from the ear in a 
rough cast of the canal and the drum-membrane. The hollow of this cast 
is dry, but the surface, which has been lying against the cutaneous lining 
of the osseous part of the canal, will be humid. This humidity is not 
due to pus, but rather to a semi-fluid sebum. The wall of the canal 
against which the seborrhoeic mass has been lying is found to be red, 
tumid, and sensitive to the touch, and sometimes granulations, or even 
polypoid exuberances of the latter, are present. This disease is very 
frequently mistaken for eczema, but eczema rarely attacks the canal. If 
eczema is found in the canal, it will be seen that the auricle is also 
eczematous. In the disease under consideration, however, the auricle is 
entirely unaffected. These seborrhoeic masses form very rapidly — often 
in the space of a week — after the disease is fully developed. 

Treatment. — The seborrhoeic masses must be carefully removed and 
the tumid and diseased surface of the skin of the canal treated. At the 
same time the general health, which is often found depraved, must be in- 
vigorated. The administration of Fowler's solution will greatly facilitate 
the cure of the skin disease in the ear. The local treatment should con- 
sist in the application to the diseased skin of an ointment containing 
ammoniated mercury gr. x to vaseline ^ i, or hydrarg. ox. rubri gr. x to 
vaseline E i. This may be put into the ear by the surgeon by means of a 
cotton dossil on the cotton-holder. Insufflations of boric acid will be of 
use in this disease, applied by the surgeon from time to time, after the 
inspissated crusts have been removed and the diseased surface fully 
exposed. This treatment must be kept up for several months in some 
cases before the cure is effected. The prognosis is always favorable. 

Ingrowiyig Sairs from the Tragus resting on the Membrana Tympani. — 
Sometimes, though rarely, the growth of hair on the tragus may be so 
exuberant as to block up the external meatus or pass into the canal and 
rest upon the drum-head. In some instances the entire auricle, esi)ecially 
at the helix and tragus, may be the seat of excessive and almost ludicrous 
pubescence. In such cases of excessive quantity of hair near the auditory 
canal, loose hairs may get into the auditory passage, or masses of them 
block it up so as to induce hardness of hearing. 

The symptom of single hairs on the drum-head will be a scraping 
sound heard only by the patient whenever the jaws are moved. If ceru- 
men aid in the matting of the hair about the external meatus, consider- 
able deafness may be the result. 

Treatment. — If the hairs have led to obstruction in the canal, the for- 
eign mass must be removed on general principles. Solitary hairs resting 
upon the membrana tympani may be lifted away by the slender forceps 
(Fig. 60) under illumination by the forehead- mirror. 



FOREIGX BODIES IX THE EXTERNAL EAR. 109 



FOEEIGX BODIES FE03I TTITHOUT. 

Inanimate Objects. — From time immemorial children have pretended 
to be able to place various kinds of seeds, beads, etc., in one ear and 
bring them ont at the other, for the amusement of themselves or their 
younger and more ignorant comi)anions. Children are very fond of 
sti'oking their faces with beads or any similar object having a polished 
surface. It is while thus amusing themselves, by stroking their ears, 
that beads, etc., often slip into the auditory canal. The variety of such 
bodies found in the ear is endless, consisting of wads of paper, all kinds 
of seeds and small beans, beads, round tij)S of pencils and x)enholders, 
pieces of slate-pencil, little stones, buttons, etc. Usually the foreign 
body is placed in the ear by the victim ; sometimes it is pushed in there 
slyly by his playmates. Sometimes during quarrels various long objects, 
such as straws, pencils, penholders, bodkins, etc., are thrust into the ear 
maliciously, both among children and adults. 

Foreign bodies often remain some time in the ears of children without 
doing harm. If a foreign body is found by chance in the ear of an adult, 
it may be learned upon incxuiry that it was put there during childhood. 

Irritant Fluids. — Melted lead, boiling oil, and other scalding fluids are 
sometimes poured into the external ear in malice or in ignorant endeavors 
at curing partial deafness. It is needless to say that all such procedures 
are not only painful but very dangerous to life. The resultant cicatriza- 
tion in the auditory canal at least causes permanent deafness. 

Improper Attempts at Removal of Foreign Bodies. — Much injury is often 
done by laymen as well as inexx3erienced physicians in their endeavors to 
extract foreign bodies from the ear. 

Animate Objects in the Ear. — Usually, insects which are found in the 
ear have crawled or flown in during the sleeping hours of the patient. 
Of course this is most likely to happen to those who sleep upon floors or 
on the ground. Dead flies are sometimes syringed from the ears of chil- 
dren afflicted with otorrhoea, to which they are attracted by the odor of 
the discharge, but in most instances produce no i^ain or subsequent 
trouble by their presence in the ear. In some instances, however, mag- 
gots grow in the ear after it has been invaded by flies. 

Treatment ; Bemoval of Inanimate Foreign Bodies from the Ear. — TVlien 
a foreign bodj^ is said to be in the ear, the surgeon should first satisfy 
himself that such is really the case before he begins any operation for 
its removal. Grave errors have occurred from the neglect of the surgeon 
to assure himself on this point. When it is fully decided that the state- 
ment of the patient or his friends is correct, and that a foreign substance 
is really lodged in the ear, if the latter has not become irritated and 
swollen by the attempts of others to remove such foreign substance, 
usuaJJy a gentle syringing, the patient's head being inclined towards the 
affected side that gravity may aid the surgeon's efl'orts, will bring away 



110 



DISEASES OF THE EAE. 



Fig. 72. 



tlie foreign body. In order to carry this out in very young children^ 
already alarmed by the accidental entrance of the foreign body, we may 
have to resort to etherizing the patient. In any case, when syr- 
inging will not remove the foreign substance and the ear is 
at all inflamed and swollen, nothing more forcible than syr- 
inging should be attempted until the local irritation is al- 
layed. Too often the attempts at removal of a foreign body 
from the ear are far more injurious than its iDresence in the ear. 
It may be said that all insoluble substances will do no harm to 
the ear if let alone. They should be removed in order to 
prevent mechanical obstruction and deafuess, but there is no 
need of haste. 

If syringing ivith icarm ivater ivill not 7^emove a foreign body 
from the ear^ other means should he cqjpUed only by mi expert. 

Bemovcd by Small Hook. — ^ext to the use of the syringe in 
simplicity and safety in the removal of a foreign body from the 
ear is a small hook (Fig. 72). Under good illumination of 
the external ear, for there must be no groping in the dark, this 



Fig. 73. 




Removal of a foreign body from the external ear. (W. B. Dalby.) 



hook may be inserted behind the foreign object, as in Fig. 73, 
and the substance gently drawn to the external meatus. 

For the removal of impacted foreign bodies, either organic 
or inorganic, the late Samuel Sexton, of ^ew York, devised 
the instrument represented in Fig. 74. Needle points have been 
substituted for the teeth of the bullet-forceps, being set at such 
an angle that when closed against a presenting surface of what- 
ever shape they seize it by the approximation of the two blades 
in the handle. This is done by pressure of them between the 
thumb and forefinger, which forces the sliding ring over the 
blades which are armed with the needle-point teeth. The latter sink 
into any substance of an organic nature, taking a profound hold on it 
and permitting great traction. 



FOREIGN BODIES IN THE EXTERNAL EAR. 



Ill 



Fig. 74. 



Removal of foreign bodies from the ear hy incision through the cartilaginous 
canal from uithout and behind the auricle was proposed by Paul, of ^gina. 
The usual mode of procedure is to make 
an incision above and behind the auricle 
in the mastoid region, down to the bone, 
and lay the auricle and cartilaginous 
canal forward towards the cheek until 
the insertion of the cartilaginous with 
the osseous canal is reached and plainly 
laid oi>en to view. The posterior attach- 
ment of the cartilage to the bone is then 
cut through above and behind and the 
foreign body grasped by delicate forceps. 
Great care must be taken not to sever 
the cartilage entirely from the bone. 

Removal of Animate Objects from the 
Ear. — Insects in the ear may be killed 
with a few drops of sweet oil and then 
removed bj^ sj^ringing. If maggots gain 
a hold in the ear, they may be killed by 
instilling a few drops of ether or chloro- 
form into the external ear. After they 
are thus killed they may be removed 
by syringing or by means of a hook (Fig. 

72) or forceps (Fig. 74) under proper illumination by a forehead- mirror 
or an electric head-lami^. 




Sexton's foreign-body forceps ; 
natural size. 



two- thirds 



CHAPTEE XL 

EESULTS OF INFLAMMATION AND INJURIES OF THE EXTERNAL 

AUDITORY CANAL. 

JEar of the JVew-Born Child. — If the external ear and auditory canal of 
the new-born child is let alone, no inflammation will occur in it from 
retention of natural secretions. These will be removed by the natural 
outward growth of the skin of the external auditory canal. Unfortu- 
nately, the new-born child is very often the victim of swabbing and wash- 
ing of its auditory meatus and canal. These mauij)ulations often induce 
infection and inflammation of the skin in the ear, and in many cases lead 
to perforation of the membrana and to otitis media, with subsequent per- 
manent deafness. 

Abscesses in the external auditory canal sometimes evacuate their 
contents through the duct of Steno, or through the clefts found in the 
anterior part of the cartilage of the auditory canal. 

Caries of the meatus may follow inflammation of the external ear. I 
removed, not long ago, an annular sequestrum from the auditory canal of 
a lady who had long suffered from otorrhoea. The sequestrum acted 
like an irritating foreign body, and its removal was followed by recovery. 

Fracture of the Tympanic Bone. — The tympanic bone, which enters 
largely into the formation of the posterior boundary of the glenoid 
cavity, as well as into the formation of the anterior wall of the osseous 
auditory canal, may be fractured by falls or blows upon the chin or upon 
the cheek. The hemorrhage from the ear which usuall}^ occurs in these 
cases has at the outset often misled the surgeon into diagnosticating frac- 
ture of the base of the skull. This mistake is all the more likely to be 
made if the patient is unconscious when first seen. Very often, however, 
the patient is not unconscious, but complains of pain in his ear, espe- 
cially upon moving his jaw. The latter symptom, together with the 
swollen meatus and the detection of a projection of bone from the an- 
terior wall of the canal into the caliber of the latter, will enable the sur- 
geon to make the diagnosis of fracture of the tympanic plate. These 
fractures of the tympanic bone are usually compound, and hence semi- 
detached parts of the skin of the auditory canal may be seen projecting 
into the canal. 

Treatment. — Excessive hemorrhage should be checked in a way not 
injurious to the drum-membrane. Hence cold water should not be 
syringed into the ear. Any portion of bone projecting into the canal, 
against or through the drum-membrane, should be carefully pushed back 
to its place or, if loose, removed from the ear. Healing should be con- 

112 



INJURIES OF THE EXTERXAL AUDITORY CANAL. 113 

ducted so as not to permit encroachment upon the caliber of the canal. 
This can be effected by the judicious use of bougies or tents in the canal 
until healing has taken place. 

Bleeding from the Meatus. — Hemorrhage from the ear occurs not un- 
commonly from traumatic causes which apparently produce no further 
lesion. A phj'sician informed me recently that, slipping suddenly, he 
struck his mastoid process violently on a i)rojection of some kind in his 
office. The blow was followed by hemorrhage from the meatus, but by 
no further trouble. The hemorrhage in such cases comes from a fissure 
in the skin of the external auditory canal, in its osseous portion. Hem- 
orrhage from the meatus, connected with injuries to deeper parts of the 
ear, will be considered farther on. when alluding to injuries of the in- 
ternal ear. 

Treatment. — If the bleeding is due to an injury limited to the skin of 
the external canal, a mild styptic may be required. In any event the 
blood must not be allowed to form permanent clots or crusts in the 
meatus. 

Vicarious Menstruation from the Auditory Canal. — Bleeding from the ear 
has been observed in some instances of suppressed menstruation. It may 
be preceded by i:>ain and a sense of fulness in the ear, which, however, is 
relieved by the hemorrhage. It may occur from a sebaceous tumor in the 
meatus, or from the mucous membrane of the middle ear. 

Epileptiform Sympftoms from Irritation in the Auditory Canal. — It is 
well known that irritation set up in the auditory canal by the presence 
of a foreign body will j)roduce epileptiform and even paralytic symj)- 
toms. 

Far-cough. — Ear-cough, a peculiar reflex cough excited by irritation 
of the external auditorj^ canal, was known to medical men a long time 
ago. 

Ear- cough is due to the fact that irritation of the auricular branch 
of the x^neumogastric nerve, distributed to the auditory canal, is reflected 
to the motor fibres of the suj)erior laryngeal nerve, also a branch of the 
pneumogastric. This induces contraction of the crico-thyroid muscle, 
which manifests itself in coughing and, in some instances, vomiting. 
Sometimes otitis externa diffusa will likewise produce the most distress- 
ing ear- cough, as will also hardened masses of cerumen in the ear- canal. 

Chronic Circumscribed Ulceration of the External Auditory Canal. — 
Chronic diffuse inflammation of the external auditory canal sometimes 
ends in the formation of distinct and circumscribed ulceration at one spot 
in the passage-way. From this diseased point an inflammatory process 
may be communicated to the tympanic cavit}'. and hence ulceration of 
the external auditory canal becomes of importance. The ulcers espe- 
cially alluded to here are found in the unyielding skin of the bony por- 
tion of the auditory canal, and by their general features of chronicity and 
sluggishness remind one of the ordinary leg ulcer. They throw off a 



114 DISEASES OF THE EAR. 

scanty dark gray or greenish discharge, somewhat offensive, and showing 
a tendency to form a dark crust around the mouth of the canal. 

Sometimes the discharge seems to have ceased, but in a few days it 
returns again, and, if allowed to run on, the disease will tend to form 
polypi and to attack the drum-head. The latter becomes congested^ all 
its normal features are lost, and uj)on syringing the ear, water may pass 
into the nose and throat. Up to this time the hearing may not be much 
impaired, for the middle ear has remained intact. Upon the occurrence 
of the perforation, however, the hearing is endangered. 

In any case, therefore, where there is found a discharge from the ear 
with an intact membrana tympani, the most careful search should be 
made for the cause, and, if an ulcer is found in the bony portion of the 
external auditory canal, to it the treatment should be directed. These 
ulcers, if situated in or near the membrana flaccida, may communicate 
with the upper part of the tympanic cavity. 

Etiology. — The causes of this disease are often obscure; but it will 
generally be found that a neglected inflammation in the canal has run at 
last into the chronic affection here described. 

Treatment. — The treatment* should consist in removal of any irritant 
which keeps uj) the ulcer, and in stimulation of the inflamed spot. The 
latter is best accomplished by cauterization with strong solutions of 
silver nitrate, conveyed to the ulcer by means of cotton on the cotton - 
holder. InsufiSations of boric acid, borax, borated chinoline, or borated 
resorcin will be found of great service in this affection. All discharges 
are to be most carefully cleaned out by mopj)ing with absorbent cotton, 
and the general health of the i:>atient examined into and built up if 
necessary. As scrofulous children are liable to be the subjects of this 
kind of local disease in the ear, iron and cod-liv^er oil will play a most 
important part in the treatment of these ulcerations, when occurring in 
such subjects. The applications of the above local remedies should be 
effected by the surgeon daily at the outset. The patient's ear should 
be let alone at home, unless it runs greatly, when it may be mopped out 
with absorbent cotton. The hearing is not usually affected in the early 
stages, but it will be, unless the disease is arrested. The prognosis is 
favorable if the ear is attended to in time. 

Reflex Ulceration of the External Auditory Canal. — Eeflex neuralgia in 
the ear, from the irritation of diseased teeth and gums, has been al- 
luded to and explained by the nervous connection existing between the 
mouth and the ear. We may go a step farther and explain reflex tissue- 
changes in the ear as induced in the same way. Ulceration in the an- 
terior wall of the auditory canal, near the membrana tympani, may be 
reflex in origin. Such ulceration may be due to decayed molar teeth 
in the inferior or superior maxilla on the same side. At the outset there 
is usually some pain in the ear for a day, then a discharge is observed, 
the pain having ceased. Examination may reveal a well-marked ulcer- 



INJURIES OF THE EXTERNAL AUDITORY CANAL. 115 

ated sx)ot on the wall of the auditory canal. This is usually made to 
heal in a short time, but in the course of a few days, or perhaps weeks, 
the same kind of an attack is again felt. In a case like this, a quick 
and permanent cure was effected after the removal of several diseased 
molars in the lower jaw of the same side. Such reflex tissue- changes 
in the auditory canal are evoked in the following way. Let it first be 
borne in mind that irritation proceeding from any part of the body may 
excite waves of blood-vessel-dilatation in a correlated area. In the dis- 
ease under consideration the seat of irritation is in the teeth and gums 
and the correlated area is the external auditory canal. The blood suj)- 
ply to the external auditory canal is derived from the external carotid 
artery, by its branch, the posterior auricular, and the vasomotor nerve 
controlling the caliber of these vessels is derived from the external 
carotid j)lexus of the sympathetic. The diseased teeth in the case alluded 
to were supplied by the inferior dental nerve. Now^ the large sensory 
division of the inferior maxillary nerve, from which the inferior dental 
nerve comes, is connected on its inner side with the otic ganglion. This 
ganglion is connected with the plexus of the sympathetic, controlling the 
external carotid artery-. As branches of this artery suppl}^ the external 
auditory canal, it is easily seen how this part of the ear becomes an area 
correlated to the seat of irritation in the diseased teeth, through the 
medium of the otic ganglion. Since the result of irritation at one point 
in a vasomotor tract is to suspend the inhibitory power of vasomotor 
nerves in a correlated area, the vasomotor branches of the carotid j)lexus, 
regulating the supply of blood in the external ear, lose, for the time, their 
power of controlling the caliber of these vessels, on account of the irrita- 
tion conveyed to them from the teeth through the otic ganglion. There- 
fore, the vessels in the external auditory canal become distended, and 
congestion, pain, and inflammation are the result. Treatment consists in 
placing the teeth and gums in a healthy state, and the ear can then be 
cured permanently. 

Cholesteatomatous and Exnthelial Imjyacfions in the Auditory Canal. — These 
cholesteatomatous and epithelial masses are usually found in ears which 
have been the seat of chronic suppuration, but in which the latter process 
has apparently run its course. In such cases the mucous membrane of 
the middle ear, as well as the cutaneous lining of the external auditory 
canal, seems to retain a tendency to the exfoliation of large masses of 
epithelial scales, which, accumulating in the ear, undergo a fatty degen- 
eration and give rise to various sj^mptoms, among which the more 
prominent are pain at times in the ear (but this is not a prominent 
characteristic of these formations), nausea and dizziness, with occasional 
vomiting. The hearing is, of course, impaired by the mechanical hinder- 
ance offered by these masses, which may be so large as to cause absorp- 
tion of the bone of the auditory canal and a consequent widening of this 
passage. Even greater irritation than this may ensue as a consequence 



116 DISEASES OF THE EAR. 

of the presence of such collections in the ear, and the bone structures on 
which they press may become carious. The soft tissues thus pressed 
upon ulcerate and in some instances become covered with granulations, 
and the membrana tympani and ossicles having undergone erosion, the 
entire tympanic cavity is occupied by the cholesteatomatous layers. The 
microscope reveals flattened epithelial cells and crystals of cholestearin 
as the components of these lamellated masses. This process is very anal- 
ogous to that which produces keratosis obturans (page 104). 

Treatment — The treatment of such accumulations should cousist first 
in the complete removal of the obstructive mass. This may require some 
patience, for the removal of the more external layers often reveals the 
presence of deeper and fresher ones, and in some cases new ones seem to 
form during the treatment. The latter tendency is best combated by the 
local application of an alterative astringent, as solutions of silver nitrate, 
copper sulphate, and zinc sulphate. I have found insufflations of boric 
acid and chinoline salicylate (page 103) to cure these cases promptly. 
The softening and removal of these masses is hastened by the use of solu- 
tions of sodium bicarbonate in glycerin and water. 

Setaceous Tmnors, or Wens^ in the Auditory Canal. — Sebaceous tumors, 
or wens, are sometimes found in the skin of the cartilaginous part of the 
external auditory canal. 

Treatment. — A wen in the auditory canal should be promptly incised, 
its contents evacuated, and the cavity healed from the bottom. 

Hyperostosis of the Auditory Canal. — In some instances there is found 
a general hyperostosis of the auditory canal, though most usually the 
hyperostosis is confined to its posterior wall. It is most likely to occur 
iij those who have been subjects of chronic otorrhoea, or who have been 
exposed to the frequent entrance of cold water into their ears in bathing 
and diving. 

This condition of hyperostosis demands no treatment unless it en- 
croaches upon the caliber of the canal and imi)airs the hearing. Its 
treatment will be considered farther on. 

Exostoses of the Auditory Canal. — Exostoses, or bony growths of a 
rounded, hillock-like shape, or pedicellate, are found in the external 
auditory canal. They are covered by the skin of the canal, are entirely 
painless, and the only annoyance they give is due to their encroachment 
upon the caliber of the canal. Their size varies from that of a merely 
distinguishable elevation on the wall of the canal to one large enough to 
occlude it and produce deafness. The skin covering them is a little 
paler than that of the canal. 

Etiology. — These osseous growths may be congenital, or they may be 
the result of chronic inflammatory processes in the middle and external 
ear. They are frequently found in persons who have been afflicted for a 
long time with discharges from the ear, though they are also very often 
present in those whose ears are otherwise normal. 



INJURIES OF THE EXTERNAL AUDITORY CANAL. 117 

Treatment. — Exostoses iu the external auditory canal demand no treat- 
ment, unless tliey occlude the canal and cause deafness by this obstruction. 
Then they may be bored through or cut away, as has been suggested and 
performed by several oiDcrators. 

Other forms of acquired obstruction in the external auditory canal 
may be partial or total, and may consist of cutaneous bands, diaphragms 
of skin or bone, and horny growths. 

Cutaneous Closure of the Auditory Canal. — Cutaneous closure of the 
canal at any point appears to be more frequent than bony closure. It 
may be congenital or acquired. This kind of obstruction in the canal is 
not always recognized at once, especially if the diaphragm of skin is 
stretched across the canal near the fundus ; in such a position the ob- 
struction may so closelj^ resemble a thickened drum-head as to lead to 
some confusion in diagnosis. 

In some cases polypoid growths, invading the same transverse plane 
of the auditory canal, may grow together, and, skin forming over them, 
a diaphragm is formed which stubbornly occludes the canal at that 
point. Beyond the diai)hragm the passage may be normal. 

Sometimes an orifice is found in the centre of this diaphragm, and by 
dilatation of this the diaphragm may be reduced to a simple constriction, 
and then the latter carefully widened. 

Fartial osseous closure of the canal occurs as the result of chronic puru- 
lent discharge from the ear, or from an osteitis set up by improper treat- 
ment, or other traumatic causes. In these the narrowing may be so 
great as to allow only very fluid discharges to escape, while retaining 
the more inspissated portions of pus. 

Neoplastic Diaphragm. — These may be destroyed by the cautious appli- 
cation of chromic acid to the central portions. Such formations may be 
incised, and the edges of the cut treated antiseptically until cicatrization 
of the cut edges takes place. 

Incise a diaj)hragm rather than excise it, and then dilate tlie incision 
with a drainage-tube of lead-foil, and keep the canal clean b}^ antiseptics 
until cicatrization of the cut surface takes place. 

Congenital Atresia. — The hearing may be very good in such cases. If 
so, an operation to create a j)ervious canal would be justifiable. 

Acquired Atresia and Stricture of the Auditory Canal, and its Treatment. — 
H. Schwartze^ gives as the usually accepted causes of acquired atresia of 
the auditory canal chronic j3urulent otorrhcea, especially that following 
scarlet fever, wounds, burns, and lupous, diphtheritic, and syphilitic 
ulcerations. To these he adds a new cause, arising during the last ten 
years, — viz., unskilful operations on the mastoid process. In the latter in- 
stance the atresia is the result of laceration of the posterior wall of the 
cutaneous canal by a spicula of bone or by the form of the operation. 

1 Archiv f. Ohrenh., Bd. xlvii. S. 71, and Bd. xlviii. Ss. 98, 261. 



118 DISEASES OF THE EAR. 

If in the subsequent treatment of the case this injury to the auditory 
canal is disregarded, and the granulations at the point of inj ury not held 
in check by tampons and cauterizations, a stricture will occur. If the 
opposite wall of the canal has been injured and granulations have formed 
there, the two granulation surfaces approximate and adhere, and a cica- 
tricial atresia is formed. 

For the relief of the atresia or stricture of the auditory canal, 
Schwartze has devised an operation consisting of the following steps. 
The usual incision is made behind the auricle as for a radical mastoid 
operation, and the auricle and fibro- cutaneous auditory canal detached 
from the posterior wall of the bony canal until the stricture is reached. 
The latter is then cut out of the canal and its lumen once more opened. If 
hyperostosis of the canal at or beyond the stricture is present it is chiselled 
away, and the membrana or its remnant and the middle ear and its con- 
tents inspected. The latter region is treated as in the radical Stacke 
operation if the condition of the middle-ear cavities demands it, the pos- 
terior wall of the bony auditory canal being chiselled away, the fibro- 
cutaneous auditory canal split longitudinally or horizontally, and the 
upper and lower flaps thus formed at that point sutured into the opening 
previously made in the posterior bony wall. The upper flap of the cuta- 
neous wall is sutured to the upper angle of the posterior auricular 
wound and the lower flap to the lower angle of the mastoid wound, 
and a retro- auricular ox)ening thus made for future treatment of the 
newly made external auditory canal cavity. 

In some instances the posterior wall of the cutaneous canal is sim^^ly 
split horizontally, the flaps pushed into the mastoid wound and sutured 
there, after which the retro-auricular wound is united by primary suture. 

In the eleven cases operated upon, the operation (detachment of 
the auricle and cutaneous canal and excision of the stricture or atresia 
regions) was in nine cases united to the radical operation of opening all 
the middle-ear cavities, and in only two instances was there no such bone 
operation. The result in these two cases of recurrent narrowing of the 
reinstated lumen of the canal raises the question whether it is not ad- 
visable, even in those cases in which an isolated cicatricial closure of the 
canal occurs, and when the nature of the disease of the parts beyond the 
stricture does not demand an operation on the mastoid bone, to make it a 
rule to widen the auditory canal by the concentric removal of flat layers 
of bone from its posterior wall. In any event, a study of the table of 
cases presented by Schwartze shows that in them permanent cure of the 
stricture of the canal was obtained only in those cases in which the strict- 
ure operation was associated with the radical bone operation, usually 
without the permanent retro-auricular opening. 

When we consider the fact that in most cases this operation revealed 
caries behind the stricture, the latter being of long standing, it is sur- 
prising that in such cases intracranial complications from retention of 



INJURIES OF THE EXTERNAL AUDITORY CANAL. 119 

pus have not more frequentlj^ arisen. The stricture operation resulted 
in curing the chronic suj^puration in seven of the eleven cases, in one 
instance the result is unknown, and in two cases the supi)uration still 
continued. The stricture (or atresia) was cured in seven cases, in one 
there was a relapse, and in three cases there was a partial return of the 
stricture. Schwartze asserts that the stricture and atresia ox)eration he 
has recently proi30sed is a decided improvement over the old methods 
of operating on the stricture through the external auditory meatus. 
However, as he points out, there exists at the point of the stricture 
a tendency to the formation of new bone, favoring a renewal sooner or 
later of the stricture, and depending upon causes unknown at present. 
PerhaiDS this persistent tendency to hypertrophy of the bone is the 
result of ^a chronic irritation of the skin and bone, brought about by 
the stagnation of secretions confined behind the stricture. However, if 
the operation cures the suppuration behind the stricture, life is not 
endangered bj^ a recurrence of atresia of the canal. The better results 
of the new stricture operation force us to conclude that it should in 
all cases be preferred to the old method of operating through the external 
meatus. 

Epithelial Cancer of the Auditory Canal. — Epithelial cancer may attack 
the tissues in the meatus after first appearing at or near the tragus. The 
growth at this point may rai)idly ulcerate and advance inward along the 
canal, with great pain in the ear. The wall of the meatus becomes 
covered with small, wart-like excrescences, the tissues in the canal be- 
come infiltrated and disorganized, and the membrana tympani is invaded 
and perforated. Fistulse may appear between the mastoid and auricle, 
resulting in the destruction of the canal, and in its i)lace a large oi^ening 
may be made by the disease. The articulation of the jaw now becomes 
exposed, the lymph-glands in the neighborhood infiltrated, and facial 
paralysis, with exophthalmos and blindness in the eye on the affected 
side, ensues. Death occurs in the course of a few months from the time 
of the first ulceration. The treatment can be only palliative. 

Fibroma. — Fibroma and osteo-sarcoma of the auditory canal have been 
removed successfully with the gal van o- cautery snare by Scheibe. 

Carcinoma. — Carcinoma of the auricle and cartilaginous auditory 
canal in a child of seven has been successfully oi)erated uidou by Decker. ^ 

Adeno-carcinoma of the cartilaginous auditory meatus and the squa- 
mous and mastoid i)ortions of the temporal bone, in a woman of sixty- 
two, is reported by F. B. Sprague.^ The initial symptoms in the ear — tin- 
nitus, deafness, and pain — occurred two years before the patient was seen 
by him. An oi)eration for the removal of two large tumors near the 
meatus auditorius revealed the fact that the cartilaginous part of the 

^ Ann. des Mai. de 1' Oreille, October, 1894. 
2 Transact. Amer. Otol. Soc, ^\x\y, 1899, 



120 DISEASES OF THE EAR. 

canal was encircled by a hard fibrous growth nearly filling the canal 
and extending into the glenoid fossa, but not connected with the parotid 
gland. It was also found that the upper bony wall of the external meatus 
was black and soft, the necrotic condition extending to the tympanum 
and through the entire thickness of the bone to the dura, into the mas- 
toid cells, and to the squama. The dura was dotted with isolated growths 
in several places. All the morbid growth was removed, so far as could 
be determined. Entire recovery took place in the ear, the hearing 
became normal, and the patient remained cured for six months, when 
symptoms of deeper involvement of the ear and cranium set in, and in 
two months the patient died. 



CHAPTEE XII. 

ACrTE AND CHEOXIC IXFLAMMATIOX, IXjrRIES, AXD MORBID 
GROWTHS OF THE :MEMBRAXA TYIMPAXI. 

Acute 2Iyringtfis. — In many cases it is of great clinical convenience to 
speak of an inflammation of the drnm-liead ; but it is not easy to describe, 
anatomically, such a disease of the ear. 

Clinically, myringitis may be classed among diseases of the ear, for 
the fact is that an inflammation of the skin of the external canal, or of 
the mucous membrane on the inner surface of the membrana tympani, 
having culminated in the drum-head, will produce such modifications in 
that membrane as to demand attention somewhat different from that nec- 
essary if the inflammation occurring in these constituent structures had 
localized itself elsewhere. As an idiopathic disease, myringitis is of rare 
occurrence ; as a secondary event, very frequent. ^ 

Sijnqytoms. — A tyi)ical case of so-called myringitis is characterized by 
pain and tinnitus, but not intense hardness of hearing at first. Upon 
inspection it will be seen that the membrana tymi)ani is congested, usu- 
ally very greatly if the disease has advanced, but that its position is not 
abnormal, and that the adjacent wall of the auditory canal is little or not 
at all congested. At the same time the Eustachian tube may be found 
entirely free, and the membrana tympani will give no evidence by bulging 
that there is secretion in the tympanum. 

By further watching such a case, it will be found that the membrana 
tymi^ani becomes gradually thicker from infiltration, and at last pus will 
be found on the outer surface, without the existence of a spontaneous 
perforation in the membrane. On wiping away this product of inflam- 
mation, the outer surface of the membrane will be found very red, in some 
cases almost granular, and it will bleed if touched roughly. This condi- 
tion of breaking down may go on until an ulcerated spot is at last formed 
on the outer surface of the drum-head. The latter may lead to a perfora- 
tion of the membrana tympani by erosion from without inward. In the 
mean time, however, the hearing does not suffer as it does when the 
tymi^anic cavity is primarily and chiefly affected by disease. As I have 
assured myself, by means of the catheter and by incisions through the 
drum-head, that the tympanum is free from disease in all such cases as 
could be termed myringitis, I am disposed to consider so-called myrin- 
gitis an inflammation usually, if not always, of the dermoid layer of the 
drum-head. In fact, there is in such cases a myringo-dermatitis charac- 



^ Gruber, ^lonatsschr. fiir Ohrenheilkiinde, 1875, Xos. 9, 11, and 12. 

121 



122 DISEASES OF THE EAR. 

terized by tlie formation of blebs below or behind the manubrium. It 
may occur from exposure to cold water, cold air, the entrance of any 
irritant into the auditory canal, or in the course of measles. 

Dry heat will control the pain in such cases, and spontaneous rupture 
of the blebs should be awaited. Paracentesis is rarely advisable for fear 
of ]3uncturing at the same time the other layers of the drum-membrane, 
and, by thus admitting septic serum to the drum-cavity, causing inflam- 
mation of this space. 

SypJiUitic Exudation. — Syphilitic exudation in the folds of the mem- 
brana tympani about the head of the malleus may occur in subjects with 
syphilitic history and chronic catarrhal deafness in the affected ear. 
This may be attended with X3ain in the ear and mastoid tenderness. 
Recovery occurs under the use of iodides. 

CHRONIC INFLAMMATION. 

Ulcers in the Dermoid Layer. — As a consequence of acute external 
otitis or of acute myringitis, ulcers may form on the membrana tympani. 
The first stage of such erosion would implicate the outer layer, while 
subsequent advances of the disease would involve the deeper layers. 
Hence an ulcer on the drum-head may assume a terraced shape, the 
upper stratum being the dermoid, the middle the fibrous, and the inner 
the mucous layer of the membrana tj^mpani. 

Sym])toms. — Such a process on the drum-head may be attended with 
tinnitus aurium and some loss of hearing, but x)ain is entirely absent. 
The attention of the patient is called to the ear partly by hardness of 
hearing and the subjective noise, but chiefly by the scanty and slow dis- 
charge. The scantiness and slowness of the discharge lead to a harden- 
ing of it about the meatus, and, the ear feeling dry and stiff, the i)atient 
is inclined to pick at it. By such manii^ulation, dry scales of dark 
matter are i^ulled from the meatus, and are usually another incentive to 
the patient to seek medical aid. 

Prognosis and Treatment. — The prognosis is favorable if the proper 
treatment is carried out, but, like every other aural disease, this tends to 
chronicity in the most favorable circumstances if not properly managed. 

Should the condition of the patient demand constitutional remedies 
(and it always will, according to my observation), some form of iron will 
be found of great benefit. The syrup of the iodide of iron or some one 
of the numerous preparations of iron and cod-liver oil will render good 
service in these cases. 

The local treatment is of the greatest importance in ulceration of the 
membrana tympani. It is, therefore, necessary that the surgeon should 
mop the external auditory canal, the drum-head, and the inner end of 
the canal with absorbent cotton on the cotton-holder. This should 
be done very carefully and thoroughly, under good illumination of the 
canal by means of the forehead-mirror. To attemx^t to cleanse an ear by 



INFLAMMATION OF THE IMEMBRANA TYMPANI. 123 

swabbing it out without such illumination is worse than useless ; it is 
always i^ainful and usually injurious. 

The existence of a i^ei'foration in the menibrana fiaccida, excepting, per- 
haps, the central varietj'', indicates serious disease in the upper part of the 
tympanic cavity. As the bulk of the malleus and incus lies in the dome 
of the tjmipanum, directly behind the membrana flaccida, there is neces- 
sarily an impediment offered by them to the escape of matter from the 
cavity of the drum when the only perforation in the membrana tympani 
is in the flaccid part. This subject will be considered farther on. 

INJURIES OF THE MEMBRANA TYMPANI. 

The membrana tympani is liable to a number of perforative injuries 
from without. These, while not directly interfering greatly with the 
function of hearing, unless at the same time they affect deeper part» of 
the organ of hearing, usually expose the mucous lining of the tympanic 
cavity to the direct irritation of the external air, and thus lead sec- 
ondarily to tymx^anic inflammation and loss of hearing. 

Prominent among the causes which lead to traumatic rupture of the 
drum-head may be cited ^^ boxing the ear" and receiving the force of 
a wave on the ear while bathing in the sea. The healthj^ membrane 
will usually resist these forces, but one that is any way diseased by 
fatty degeneration, atrophy, or calcareous deposits, or one prevented 
from assuming proper equilibrium by a closure of the Eustachian tube, is 
extremely liable to yield to the external violence above named. 

The drum-head may receive very injurious concussion from diving 
into the water, from the discharge of musketry or of a cannon, from falls 
or from a gunshot wound near the ear, as, for example, in the upi)er 
maxilla and the horizontal plate of the ethmoid, and also from the kick 
of an animal on the mastoid process. The membrane is also frequently 
injured bj^ the introduction of long and slender instruments into the 
auditory canal. It is often injured, in fractures of the temporal bone 
bj' blows on the chin, by impaction of the maxillary condyle against 
the anterior wall of the auditory canal and annulus tympanicus, and by 
'•'boxing the ear.'- These accidents are usually accomi^anied by hemor- 
rhage, but this, if unaccomi^anied by the escape of serum, is not a grave 
sj'mptom. The escaiDe of serum, either with or without blood, esiDCcially 
if coitions, is indicative of fracture of the base of the skull, involving 
the internal, middle, and external ear. 

Congenital Perforation. — It must be borne in mind that there may be a 
congenital perforation of the membrana tj^mpani, as shown by Gruber ^ and 
Bochdalek.^ 

The membrana tympani has been found ruptui^ed in those who have 

^ Med. Press, March 6, 1895. 

2 Praeger Yierteljahrschrift, 1866. 



124 DISEASES OF THE EAR. 

been executed by hanging. In such a case the fissure of the drum-head 
is ragged and runs from the tip of the manubrium downward towards 
the periphery of the membrane. The edges are everted, but there may 
be neither blood nor any other fluid in the cavity of the drum. From 
the eversion of the edges in such a case it might be supposed that the 
force which breaks the membrane acts from within the tympanic cavity 
outward. The rupture of the membrane may be explained by supposing 
that the air in the tymj)anum at the moment of the fall is thrown into 
violent concussion, aud^ not being able to escape by the Eustachian tube, 
owing to the constriction of that canal by the rope, is forced violently 
outward, producing the fissure of the membrana tympani. The membrana 
tympani may be ruptured hj an increase in the external atmospheric 
pressure, if the latter is very extraordinary and if the Eustachian tube is 
more or less impervious. 

The membrana tympani is probably able to endure sudden pressure 
from without, as in discharges of artillery, musketry, etc., whether ex- 
pected or not, only through the loose valve- like nature of the Eustachian 
tube. 

Fracture of the Handle of the Malleus. — There are a few cases of fracture 
of the handle of the malleus on record. This rare accident has been de- 
scribed by Meniere,^ von Troeltsch,'^ and E. F. Weir.^ 

Atrophy of the drum-head may occur in consequence of pressure, 
long kept up, by a mass of hardened cerumen. This process is favored 
if the Eustachian tube is at the same time closed.* It is not uncommon 
to find, in those suffering from chronic aural catarrh and deafiiess, hard- 
ened pieces of ear-wax in contact with the drum-head. Though such an 
obstruction may add nothing to the existing deafness, it may and often 
does produce sensations of fulness in the head, and, at times, vertigo. 
Such cases are apt to escape detection, simply because the patients have 
given up all treatment, considering their cases hopeless, and are no longer 
under examination. Although the deafness may remain unchanged after 
the removal of such masses of cerumen, the cerebral symptoms are greatly 
relieved. 

Medico- Legal Significance of Injuries to the Membrana Tympani. — After 
a blow has been received on the ear, either during a quarrel or in play, 
an action at law may be instituted to recover damages for supposed 
injury to the drum. In such a case the surgeon will be called on to decide, 
first, whether there has been an injury done the drum-head, and, second, 
if so, how far it will impair the hearing. In the first consideration he 



1 Gazette Med. de Paris, 1856, p. 50. 
^ Treatise on the Ear, p. 151. 

^ Ununited Fracture of Manubrium of Malleus, Tr. Amer. Otol. Soc, 1870, vol. i. 
p. 121. 

^ S. Moos, Archives of Oph. and Otol., 1869, vol. i. pp. 321, 324. 



INFLAMMATION OF THE MEMBRA XA TYMPANI. 125 

must bear in miud that the drum-head may have been perforated before 
the blow was received, though the patient or complainant may or may 
not know it. The chronic perforation can readily be distinguished from 
the acute, as the former is rounder and has cicatrized edges, while the 
latter is irregular in outline and often has dried blood on its edges. If 
it should be determined, however, that a previously normal drum-head 
has been ruptured by a blow on, or a thrust into, the ear, it remains 
for the surgeon to determine whether the hearing has been or will be 
impaired by the injury. The mere Assuring of a normal membrana tym- 
l^ani in the above way may not necessarily injure the hearing nor oblige 
the patient to give u}) his daily work. If, however, there has been a 
severe blow on the ear, the hearing may be impaired from concussion 
of the nerve in the labyrinth, which, though associated with mixture 
of the drum-head, is not necessarily caused by it. If there has been no 
concussion of the inner ear and no inflammation set wp in the drum- 
cavity, the rui)tured drum-head will heal quickly if let alone, — i.e., if 
nothing is dropped or poured into the ear. Ignorance on the latter 
score has led very often to the use of drops the moment a fi.ssure in 
the drum has been noticed. The matters thus poured into the canal, 
having entered the drum- cavity through the perforation, have set up 
inflammation in the delicate mucous membrane of the middle ear, and 
disease has been established where otherwise, by letting the ear intelli- 
gently alone, the perforation would have healed in a day or two. Thus, 
it might appear that a blow had caused the disease which in reality was 
produced bj^ improper treatment of the ear. If, in a case of asserted 
traumatic violence to the drum-head, deafness should be discovered by 
the surgeon, it must be determined whether it has been produced by the 
same blow which has ruptured the drum or whether it existed before. 
A temporary diminution of hearing is very likely to occur after a blow on 
the ear hard enough to rupture the membrana tympani, but if great and 
sudden deafness comes on after a blow on a previously healthy ear, and 
if it remains for several days without signs of improvement, it must then 
be adjudged permanent, and the claim for damages must be in accord- 
ance with the facts. Even should it be decided that the injured ear 
was not in a state of health before the blow, it would seem that all the 
greater claim could be made by the sufferer. In such a case, however, it 
must ever be borne in mind that it is not the fissure in the drum-head 
that has done the damage, but a consequent inflammation in the middle 
ear, or the concussion of deeper and more delicate nervous parts of the 
organ of hearing. 

Xormal Movejiients in the Membrana. — Hammerschlag ^ has demonstrated 
that there are normally motions in the membrana tympani synchronous 
with respiration as well as with the pulsations of the heart. Aural 



1 Wiener Med. Woch., September 19, 1896. 



126 DISEASES OF THE EAR. 

myoclonus has been noted by Masini ^ in three cases, all of them men the 
subjects of dyspepsia and neurasthenia. 

MORBID GROWTHS. 

Wart-like Bodies on the Memhrana Tympani. — Wart-like excrescences 
on the membrana tympani, first described by Urbantschitsch, I have ob- 
served in but one case. There were in this case — that of a man twenty- 
four years old — two x)ale yellow warts, about a millimetre in diameter, on 
the upper and posterior quadrant of the membrana tympani. There 
seemed to be no explanation for their occurrence, unless it could be 
found in the instillation of various fluids which the patient had practised 
on his own responsibility, for some time, for the cure of deafness resulting 
from chronic catarrh of the middle ear. The constant irritation thus 
ai)plied to the delicate dermoid layer of the drum-head may have 
provoked the growth of some of its papillae into the above-named wart- 
like bodies. 

Yascular Tumor Sj Moles, and Hcematoma of the Membi^ana Tympani. — Vas- 
cular tumors, moles, and hsematoma are sometimes found limited to the 
membrana tympani. These formations require no treatment unless they 
interfere with the hearing, when they may easily be removed. In pur- 
pura hgemorrhagica, purpuric spots may occur on the membrana tympani 
and cause perforative inflammation of the drum-cavity. 

Endothelial Cholesteatoma. — Endothelial cholesteatoma on the mucous 
surface of the membrana and cholesteatoma of the dermoid surface of the 
drum-membrane are sometimes observed. They may easily be removed 
with a small needle or knife if their removal seems required. 



^ Arch. Ital. di OtoL, January, 1897. 



CHAPTER XIIL 

ACUTE CATARRHAL OTITIS 3IEDIA. 

Oyee sixty per ceut. of all ear diseases are in the middle ear. More 
adults than children (three to one) and more men than women are affected 
with diseases of this part of the organ of hearing. 

Diseases of the middle ear are divided into four general classes, — viz., 
acute catarrhal, chronic catarrhal, acute purulent, and chronic imrulent otitis 
media. All these begin as an acute catarrhal process, influenced, of 
course, by special conditions of health and diathesis in the patient. As 
a rule, the acute catarrhal process of the middle ear originates in an 
acute catarrh of the nasopharynx and the Eustachian tube, whence it 
spreads to the middle ear, which in its normal state is an aseptic cavity. 
Sometimes it seems that the entrance of cold water, cold air, or some 
other irritant into the external auditory canal sets up an inflammation 
in the middle ear ; but in such cases it will be found that the nasopharynx 
was more or less inflamed and supplied the pathogenic germ to the 
drum-cavity congested from disease in the external ear, thus offering a soil 
favorable to the growth of streptococci or other pathogenic organisms. 

ACUTE CATARRHAL OTITIS MEDIA. 

Etiology. — Acute catarrhal otitis media is caused most frequently by 
acute corj^za. It is rarely, if ever, due solely to any form of inflammation 
of the fauces without concomitant nasal disease. It is also caused by the 
nasopharyngitis excited in the exanthemata, typhoid fever, and influenza. 

The acute otitis media coming on about the third week of typhoid 
fever is due to the accumulation of secretions, food, etc., and the decom- 
position thereof in the nasopharynx of the weak and recumbent patient. 
Se]3sis is thence conveyed to the Eustachian tube and middle ear. An 
acute catarrh is set up in these cavities, and a simple catarrhal otitis 
media is often soon followed by an acute suppurative otitis media. 

Symptoms. — The earliest symx^toms of this disorder are a sensation of 
stufliness in one or both ears and hissing or i^ulsating tinnitus, but with- 
out i)ain or altered hearing. Sometimes, indeed, in the early stages the 
hearing may be hypersesthetic. Most of us experience this mild stage of 
acute catarrhal otitis media with a cold in the head. As simple coryza 
passes off, all ear symptoms go with it, if the local treatment of the nares 
and nasopharynx has been mild and gentle or purely negative. If 
the conditions in our own nasopharynges and middle ears are closely ob- 
served when we have a coryza, we shall notice that, as secretion increases 
in the nasopharynx (but not before), the Eustachian tube ceases to oi)en 

127 



128 DISEASES OF THE EAR. 

at each act of swallowing as it does in a normal state. The ear may feel 
more or less stopped, and now and then there may be a slight pain run- 
ning into it from the posterior nares. If in these early stages the naso- 
I)harynx, nares, and Eustachian tube receive no local treatment, or only 
a mild one with a bland oleaginous spray, we shall perceii^e that, as 
secretion in the nares and nasopharynx diminishes, in the course of from 
three to six days, the Eustachian tube will open spontaneously (or with 
an act of swallowing) and the ear will feel clear once more. This stop- 
page of the Eustachian tube in the early secretory stages of an acute 
coryza is beneficial, since it is Nature's seal set against the entrance of 
pathogenic germs from the nasopharynx into the normally aseptic middle 
ear. If this seal is broken, either by forcible blowing of the nose, Yal- 
salvian auto-inflation, or the inflation-bag of the surgeon, it is done to the 
injury of the patient, as pathogenic germs are very likely to be forced by 
such manipulations from the nasopharynx into the middle ear and an 
acute purulent inflammation of the drum-cavity set up. Acute catarrhal 
otitis is as common as acute coryza, and as simi^le if properly managed ; 
but the transition to acute purulent otitis — a serious malady — will be 
rapid if the local treatment of acute catarrhal otitis is injudicious. 

Diagnosis. — If the membrana tympani be examined in the early stages 
of a simple acute otitis, it will be seen to have undergone very slight, if 
any, change. It may look a little pink, or even red, along the malleus 
and periphery, but its general surface undergoes no change in appear- 
ance or position. 

Treatment — All forms of inflation and aspiration of the middle ear, 
as also syringing and douching the nares and nasopharynx with watery 
solutions, must be most carefully avoided, since all of these manoeuvres 
tend to force pathogenic germs from the nasopharynx into the middle 
ear. If the nares and nasopharynx are full of tenacious secretions which 
the patient cannot gently blow from the nose, a moderate use of a spray 
of Dobell's solution, or simple fluid petrolatum, once or twice daily for 
a few days will soften these secretions and favor their outflow ; but no 
inflations or aspirations of the nasopharynx should be employed to open 
the middle ears. Both doctor and patient should be taught that the 
stopped condition of the ear or ears is a preventive of worse conditions 
in the ear, and must be cheerfully endured for a few days. The contin- 
ued use of watery sprays must be avoided, as they tend to ^'water-log" 
the tissues and increase the swelling and discomfort in the nose. 

The acute catarrhal otitis media of the exanthemata, of typhoid fever, 
and of grippe originates also by infection from the nasopharynx, but, 
owing to the more weakened condition of the patient in these maladies 
than in sim^Dle coryza, it tends to a more virulent course from the outset. 
E'evertheless, the simpler the local treatment of the nasopharynx and ear 
in such cases the less likelihood there will be of secondary infection 
and the more favorable will be the course of the aural disease in the end. 



ACUTE CATARRHAL OTITIS MEDIA. 129 

A mild antiseptic nasal spray to cleanse the nasopharynx a few times 
daily in such cases will be sufficient. 

If there be pain in the ear, it can be allayed best with dry heat 
applied by means of the hot- water bag, hot-water bottle, or hot stone 
wrapped in flannel. The endeavor to open the stopped ear and to relieve 
slight ear-pains by inflations, aspirations, and syringings has often con- 
verted simple catarrhal otitis media into painful and serious acute purulent 
otitis media. 

Simple catarrhal otitis media, even when painful, can be allayed by 
the application of dry heat about the ears, combined, in those instances 
demanding it, with an antifebrile treatment of the general system, if this 
plan is pursued from the outset of the inflammation. There will be no 
harm in instilling into the ear, if it i:)ains, ten drops, ivanned, of a watery 
solution of carbolic acid (1 to 40), or one of formalin (1 to 1000), if these 
can be borne. 

The advantage of instilling an antiseptic into the inflamed ear in the 
•early stages before perforation of the drum-membrane occurs is that the 
auditory canal is thus rendered to a great degree aseptic ; hence it is a 
safer place for the membrana to rupture into, since, when the membrana 
ruptures and the germs causing the acute inflammation are poured into 
the outer ear freed from stai)hylococci bj^ antiseptic instillations, there 
is less danger of the entrance of the last-named germs, the j^romoters 
of chronic purulency, into the drum-cavity, and secondary infection is 
less likely to occur. 



CHAPTER XIY. 

CHRONIC CATARRHAL OTITIS MEDIA. 

Every case of acute catarrhal inflammation of the nasopharynx affects 
the ears to some extent. This aifection may be only a slight sense of ful- 
ness, passing off with the coryza, or there may be a slight dulness of 
hearing remaining after the acute catarrhal symptoms have passed away. 
This dulness of hearing may increase after each cold in the head, to 
which, probably, the patient is specially liable. In other instances the 
acute catarrhal inflammation i)asses into an acute purulent inflammation 
of the middle ear, to be considered farther on. At present it seems 
convenient to consider those cases that pass from an acute catarrhal 
into a so-called chronic catarrhal inflammation of the middle ear ; these 
are characterized by disturbances in the trophic nerves of the middle 
ear. The process at first is usually hypertrophic, but at last there is a 
distinctly sclerotic condition brought about in the mucous membrane of 
the middle ear, which process in many cases extends to the internal ear 
and impairs the acoustic nerve. In only one-quarter of the cases of 
so-called chronic catarrhal deafness can nasal obstruction be regarded 
as causing loss of hearing. Too much and too severe treatment has 
been directed towards hypertrophies of the turbinates as a means of 
curing deafness. Especially to be condemned in this connection is tur- 
binotomy. 

SUBJECTIVE SYMPTOMS. 

Tinnitus. — The earliest subjective symptoms of this disease are tinnitus 
aurium and a gradual diminution of the hearing. These symptoms api)ear 
usually only in one ear at a time, and a varying period may elapse before 
the other ear is attacked. The onset of the subjective noise in the ear 
may be quite sudden 5 the time of its first occurrence can usually be 
stated accurately by the patient. This buzzing, chirping, or hissing 
may appear on rising in the morning, during or after a severe cold in 
the head, or after a depressing illness. The noise is not intense at first,, 
but gradually becomes louder and more annoying, the hearing usually 
diminishing at the same rate. The statements of patients as to the 
quality and character of the subjective aural noise vary extremely. 
The objective sounds to which they are likened are commonly taken from 
the sounds to which the patient is most exi)Osed. In many cases a hyj)er- 
sesthesia to objective sound seems to come on with the annoying subjective 
noises. All subjective noises of the ear in this disease may be increased 
by fatigue, drinking spirits, smoking, and prolonged conversation. In 
some cases the noise seems much louder after each meal. Some authori- 
130 



CHRONIC CATARRHAL OTITIS MEDIA. 131 

ties state ^ that abnormal conditions of the genito-urinary apparatus tend 
to aggravate the tinnitus of chronic aural catarrh. It is very certain that 
gastric and intestinal derangements tend to make tinnitus aurium more 
intense. But in some cases tinnitus aui'ium either never appears in the 
disease or only at a later stage, long after the hearing is much reduced. 
These cases, being deprived of the warning as to the threatened failure 
of the function of the ear found in tinnitus aurium, are rarely made 
aware of the loss in hearing until it becomes very great. This is espe- 
cially the case when one ear remains perfect. A failure of hearing in 
the good ear, temporary or otherwise, is often the first occasion for 
noticing the defect in the other ear. 

The coming on of this kind of deafness is so insidious that in many 
cases, even among the most intelligent, there is no reliable history of the 
origin of the disease. These cases with no definite account of the be- 
ginning of deafness seem, in my experience, to belong to a class with 
hereditary tendencies to chronic catarrh of the nasopharynx and middle 
ears. 

Fain. — Darts of x)ain are felt in some cases every day or two, but this 
is not a very frequent symj)tom. If it occur, it is only in the earlier 
stages. Most patients complain of fulness and discomfort in the ear as 
the disease advances. If the secretion of mucus is considerable, more 
or less cracking is heard in the ear by the patient. After the ear cracks, 
it seems open for a little while, and the patient may hear better. But 
in a short time the feeling of stoi^page returns, and the hardness of hear- 
ing is again i)resent. The pain and the sense of fulness are increased 
by changes in the weather during the winter season. In summer all such 
symptoms are very much less i)rominent. 

Fauces. — With the tinnitus aurium, loss of hearing, and darting pain 
in some cases, disagreeable sensations are felt in the fauces, throat, and 
larynx. The character of these subjective conditions is variously de- 
scribed by the sufferers. Most of them com^Dlain, however, of constric- 
tion, tickling, sensation of fulness, and bm^ning in the throat. All of 
these are aggravated by cold, by any depressed state of health, by stimu- 
lating food, and by dyspepsia with constipation. In some instances, after 
a hearty meal, the throat will feel more or less burning, which is aggra- 
vated if the patient is obliged to talk for any length of time. Yery often 
the disagreeable feeling in the throat is described as like that caused by 
a hair or other foreign substance lying in the fauces, and which remains 
there notwithstanding all efforts at swallowing. 

Far-Vertigo. — Attacks of ear- vertigo come on suddenly, occurring once 
or twice a year at first, and are usually not referred to the ear as a cause 
either by the patient or his physician. In fact, they are commonly con- 
sidered and treated as attacks of stomachic vertigo or as neurasthenia. In 



^ Weber-Liel, Progressive Schwerhorigkeit, S. 19. 



132 DISEASES OF THE EAR. 

some instances the attacks of ear-vertigo are preceded by an increase in 
the tinnitus aurium, and this may arouse in the patient a susiDicion that 
the ear disease is the cause of his vertigo. When chronic ear- vertigo sets 
in, it is in the later stages of chronic catarrhal deafness, and the deafness 
is generally profound in the ear or ears affected. In every case of chronic 
catarrhal otitis media there occur, very early in the process, contraction 
of the tensor tympani, retraction of the chain of auditory ossicles, and 
consequent impaction of the stapes in the oval window. It is this last 
event that causes compression of the intralabyrinthine fluid and irrita- 
tion of the motor filaments of the auditory nerve and cerebellar pedun- 
cles, with reflex phenomena of vertigo. 

If these attacks of ear- vertigo once set in, they gradually increase in 
frequency from once in six months to once a month, and finally once 
a fortnight. As the patient suffers from nausea and vomiting, as well 
as inability to walk steadily, or even at all, and as he may be seized by 
vertigo in the street and be mistaken for a drunken man, he is unwilling 
to leave the house alone. His business is interrupted, his nervous force 
gives out, and his general condition becomes deplorable. Unfortunately, 
he is often treated now for '^neurasthenia," '^ epilepsy," and even 
'' apoplexy," instead of ear- vertigo. The fact that a i)atient with ear- 
vertigo never loses consciousness in his attacks serves to render the dif- 
ferential diagnosis positive. 

Searing Better in a Noise. — Hearing better in a noise is very often a 
marked symptom of the later stages of chronic aural catarrh, when the 
tympanum has become dry and sclerotic, or when the thickening of the 
mucous membrane has become great in the moist form of the disease. 
Those presenting this symptom (^Paracusis WiUisiana) are found upon 
examination to hear the ticking of a watch somewhat better in a noise — 
for instance, in a mill or a railway train — than in a quieter place. No 
entirely satisfactory explanation of this condition has yet been given. 

OBJECTIVE SYMPTOMS. 

Appearances in the External Auditory Canal. — It may be said that in 
chronic aural catarrh characteristic changes occur in the external auditory 
canal. Chief among these is the diminished or suspended secretion of 
cerumen. The ear-wax not only becomes smaller in amount, but often 
assumes a brittle quality ; later it often ceases to be formed at all. This 
points to a great alteration in the nutrition of the organ of hearing. 
This important excretion ceasing to be poured into the auditory canal, 
there set in a dryness and scaly condition of the skin of the meatus. 

Menibrana Tympani ; Changes in Color. — The membrana tympani usually 
loses its lustre and transparency in chronic aural catarrh. But as these 
changes are not always indicative of such a disease in the tympanum, 
they must never be regarded as of positive value. In some cases of 



CHRONIC CATARRHAL OTITIS MEDIA. 133 

chronic catarrh of the middle ear the membrana tympani may be thinner 
than usual, and cases are observed in which the lustre remains un- 
changed. In the latter instance the chronic alterations in the mucous 
membrane of the middle ear have occurred elsewhere than on the inner 
surface of the drum-head ; in fact, these usually take place at the stapes. 
The membrana tympani may appear uniformly jDink from the trans- 
mission of the redness of the congested mucous membrane on the promon- 
tory. Another important fact to bear in mind respecting color- changes 
in the drum-head is that, even in those with normal hearing, especially 
in children, the membrana tymi^ani is not infrequently rather dull in 
appearance for longer or shorter periods. The lustre of the membrane is 
most easily lost 5 alterations in tenuity are more indicative of a decider 
change in structure. 

Calcareous Deposits. — Chalky spots may be found in the drum-head of 
an ear affected by chronic catarrh, bat they cannot be considered charac- 
teristic of the disease. They are usually traceable to a previous purulent 
disease in the ear, all other traces of which have gone, for it is not uncom- 
mon to find these deposits entirely unaccompaniedby hardness of hearing. 

Changes in Position of the ITenibrana Tympani. — A much surer objective 
symptom of chronic aural catarrh, especially when joined to opacity and 
loss of lustre, is a retraction of the membrana tympani. The drum- 
head then appears drawn in and the manubrium of the malleus fore- 
shortened, the short process of the latter projects more sharply than 
usual, and the folds of the membrana tympani are very prominent. The 
manubrium is not only indrawn, but is pulled backward and upward, 
and, the entire concavity and curves of the drum-head being thus altered, 
the i^yramid of light, normally found in the antero-inferior quadrant, is 
very much changed in position, or it may disappear altogether. As the 
latter reflection depends on the lustre as well as the curve and position 
of the drum-head, and as more or less opacity is found in chronic aural 
catarrh, the normal pyramid of light is usually one of the first featui^es 
to vanish from the diseased membrane. The manubrium not only is 
indrawn, but it is rotated about its long vertical axis so as to pull the 
posterior half of the drum-head into greater prominence and to drag the 
anterior half into a greater depression. 

Xares. — The changes in the nares often attending, and apparently in 
many cases promotive of, chronic aural catarrh may be very great. 
Most important is hypertrophic catarrh of the nares in these cases. The 
hypertrophy is usually most prominent on the inferior turbinated bones, 
though it may invade all the membranous structures of the nostrils, either 
on the turbinated bones or upon the septum. Posterior nasal hypertro- 
phies are the most important, on account of their proximity to the faucial 
end of the Eustachian tube. There are often found enchondromatous 
enlargements on the septum, deviations of the septum, and other forms 
of obstruction in the nares in the subjects of chronic aural catarrh. 



134 DISEASES OF THE EAR. 

These obstructions, augmented by the hypertrophic mucous membrane, 
interfere with normal nasal respiration and lead to mouth-breathing. 
Thus the throat becomes affected by the irritation of direct respiration, 
and the nares and nasopharynx become further affected by being de- 
prived of the normal stimulus of nasal respiration. The Eustachian tube, 
deprived of the natural stimulus of nasal respiration, fails to become 
patulous as often as it should, and may remain closed for long periods, 
and the drum-cavity is thus deprived of its normal quantity of ventila- 
tion. This condition, in turn, retracts the membrana tympani, fixes the 
ossicles, and tends to the production of ankylosis in the sound -conducting 
apparatus of the middle ear. 

The Condition of the Fhay^ynx and Throat. — The pharynx, tonsils, and 
velum will be found to present varying appearances according to the form 
of the disease. 

In the moist form the secretion of mucus will be markedly increased 
and the glandular structures of the mucous lining of the fauces will appear 
enlarged and inflamed, their function at first being, of course, stimulated 
by the disease. The tonsils are usually very much enlarged in this form 
of the disease, and the velum appears swollen. But this tonsillar hyper- 
trophy is only an accompaniment of the general catarrh, not the cause of 
the catarrh in the ear nor of the hardness of hearing. It will very often 
be found that the most swollen tonsil is on the side of the better ear. The 
secretion of the nose is also very apt to be abnormally great. 

Sclerotic Symjptoms. — But many cases of chronic aural catarrh do not 
continue to show this abnormal amount of secretion in the pharynx. In 
these cases the mucous membrane has either rapidl}^ ceased to throw off 
large quantities of mucus or it has slipped at once into an atonic and 
dry state. In such cases the mucous membrane of the entire pharynx, 
especially on the posterior wall, is pale and, at spots, apparently absorbed. 

The velum appears rather thinner than natural, as though its muscular 
structures were absorbed, as indeed they are ; and the raphe is no longer 
directly in the median line, nor are the halves symmetrical in shape 
and position. A paresis has apparently affected one-half more than the 
other, and the uvula and the weaker half will be drawn towards the 
stronger side, which will usually be found to agree with the better ear. 
All of these changes in the action of the muscles of the fauces must be 
attributed to the effects of the catarrh. 

Loss of Function in the Velum. — The loss of normal mobility in the 
velum is further seen when the patient is told to phonate the vowel a 
broad. Then the velum and uvula, instead of rising quickly to shut off 
the lower from the upper pharynx, will fail more or less to fulfil this 
function. The uvula either hangs loose and downward, quite relaxed, or 
it clings to one or the other side, on the edge of the velum. As the 
patient phonates, the uvula may slip from this position on the velum and 
hang loosely downward, or it may curve forward, or backward against 



CHRO^'IC CATARRHAL OTITIS MEDIA. 135 

the posterior wall of tlie i^haryux. In such eonditionSj sudden eructa- 
tion, coughiug, or sneezing may at times produce pain in the ear. It is 
also very noticeable that the act of swallowing cannot be performed 
rapidly by persons thus affected in the faucial muscles. 

Changes in tJie Voice. — With these alterations in the ear and throat, 
the vocal functions usually become weaker. The timbre of the voice is 
altered, and, if the patient has been a singer, the voice is found to be 
rapidly losing musical power. A kind of hoarseness sets in when sing- 
ing or prolonged conversation is attempted. The voice '"breaks" or 
^'cracks," and a general sense of fatigue in the throat becomes a promi- 
nent and distressing symptom. All of these alterations in the throat 
usually begin to appear before the morbid changes in the ear. The latter 
seems to become affected by a passing inward and upward of the nasal 
and throat disease through the tube into the tympanic cavity. When 
once there, a long series of nutrient changes begin, which, with varying 
symi)toms, usually terminate in total deafness ; though in some cases 
chronic aural catarrh seems to stand still after having impaired, but not 
destroyed, the function of the ear. A marked characteristic of chronic 
aural catarrh is not only to advance slowly and surely in one ear, but to 
pass to the other sooner or later. 

Objective Changes in the Eustachian Tube. — As may be inferred from 
what has been already said, the Eustachian tube, being lined with mucous 
membrane continuous with that of the fauces and of the tympanic cav- 
ity, and forming such an imi:)ortant part of the middle ear, undergoes 
serious and most important changes in clironic aural catarrh. These 
changes are due primarily to thickening of the lining of the tube or to 
obstruction of its caliber by mucus. 

Adenoid Groidhs and Granulations in the Xaso2)hanjnx. — In a number 
of cases of chronic aural catarrh there are found adenoid growths and 
granulations in the nasopharyngeal space. These growths are described 
as benignant in nature and more or less leaf-like or conical in their 
shape. They are usually situate quite high in the nasopharynx, are 
extremely delicate, and hence bleed on being touched. Their height or 
length rarely exceeds three centimetres, and their breadth or thickness 
varies from a few lines in the smallest to one or two centimetres in the 
largest. As might be supposed, such growths interfere not only with 
respiration and enunciation, but also with the normal ventilation of the 
Eustachian tubes and tympana. 

The symptoms are a tendency to bleed whether touched or not, altera- 
tion in the pronunciation of certain vocal sounds, as m, n, and ng, and a 
great change in the facial expression, from the falling in of the aloe of 
the nose and the respiration through the mouth necessitated by the ob- 
struction in the posterior part of the nares. The hearing, too, will in 
time become greatly lessened from the chronic stoppage in the Eustachian 
tubes and the interference with the normal ventilation of the middle ears. 



136 DISEASES OF THE EAR. 

A nasopharynx thus affected is apt to secrete large amounts of tough 
greenish mucus, the velum may be swollen, and the lower pharynx 
chronically inflamed. On the other hand, these growths may be present 
in the nasopharynx without any marked accompanying changes in the 
pharynx and velum, ^ot uncommonly, the altered enunciation, respira- 
tion, and facial expression arouse a suspicion of their presence, which is 
subsequently confirmed by rhinoscopic examination and manipulation 
with a probe or the finger, the latter causing the growths to bleed. 

The Objective Effects of Diagnostic Inflation upon the Memhrana Tym~ 
pani. — The effects of inflation upon the membrana tympani are among 
the most important objective symptoms. More or less bulging of the 
drum-head will be caused by inflation. If the handle of the malleus is 
held retracted, by alteration in the mobility of the tendon of the tensor 
tympani, this bulging of the membrane will occur behind and before the 
manubrium ; but if the manubrium is not held in, as above suggested, 
then it and the membrane will be moved more or less as a whole. At the 
same time, if there is movable fluid in the cavity of the drum, it will be 
forced against the membrana tympani and modify the picture presented 
to the observer. Bubbles may be seen then distinctly through the mem- 
brane, or inspissated secretion may be found to change position in the 
drum. 

A most interesting and instructive change, produced by inflation, in 
the appearance of the drum-head is the forcing outward of depressed 
spots or cicatrices. Unless this symptom is sought for promptly after 
the air is forced into the tympanum, it may escape notice. 

Yery often depressed cicatrices are considered retractions adherent to 
the inner tympanic wall, but on inflation these deiDressious may not only 
return to the x)lane of the rest of the drum- head, but not uncommonly 
they project beyond it into the auditory canal, forming thus blister-like 
spots. In some cases these are filled only with air ; in other cases they 
are filled with brownish fluid, which will give them an amber tint. ]N"ot 
only will these appearances come out on the drum-head by inflation, but 
they can be produced very easily under suction by Siegle's pneumatic 
speculum. 

This latter method of examination of the drum-head is of the greatest 
value, for, when the tube is stopped up and absolutely impervious to air, 
the pneumatic speculum or its equivalent becomes the only means of 
producing movements in the drum-head, and secondarily of the contents 
of the drum -cavity. 

^N'ot uncommonly inflation of the tympanic cavity, especially by 
Valsalva's or Politzer's method, produces objective sounds, readily 
audible without the aid of the auscultation- tube. Especially is this 
observable when the entire drum-head is flaccid and easily moved to and 
fro, or when, in a comparatively normally tense membrane^ flaccid scars 
are found. 



CHRONIC CATARRHAL OTITIS MEDIA. 137 

Tlie sound produced in either instance is that of a loose crackling of 
the flaccid tissue. In a case recently observed, so loud was this crackling 
sound that it was heard across a large room, not only during Valsalva's 
method of inflation, but also during rapid breathing through the con- 
gested nares, the mouth being kept closed. Valsalva's method of auto- 
inflation consists in closing the mouth and holding the nostrils with the 
fingers, while the breath is forced into the Eustachian tubes and tympanic 
cavities. 

Malignant Growths in the Nasopharynx involving the Ear. — Malignant 
neoplasms in the nasopharynx may involve the ear at an early period of 
their growth, as shown in a case of small-celled sarcoma in the vault of the 
pharynx, observed by the author. 

Emphysematous Tumor over the Mastoid. — Xatural dehiscences in the 
mastoid j)Oi*tion of the temporal bone sometimes i)ersist, and favor the 
escape of air from the middle ear and mastoid cavity to beneath the skin 
lying over the latter, as has been observed in a case reported by Wernher. 
Compression long kept up having failed, in the case reported, to i)roduce 
a cure, a successful endeavor was made to set up adhesive inflammation 
between the edges of the dehiscence and the superjacent soft tissues. 
This was accomplished by means of subcutaneous injections of tincture 
of iodine at various x>oints in the tumor. 

Hairs in the Mastoid Cells. — Another curious condition of the mastoid 
cavity is the occurrence of hairs within it, as related by the late Mr. 
Toynbee. The hairs in this case were firmly embedded in the mastoid 
cells and surrounded by masses of epidermis. 

Objective Snapping Xoises in the Ear. — Sometimes there occurs in 
chronic aural catarrh a snapping noise in the ear, which is audible not 
only to the sufferer but to others. This noise has been likened to the 
snapi^ing of the fingers, or to the sudden drawing apart of the finger- 
ends when slightly moistened with saliva or a tenacious fluid. 

The spasms in the muscles in such cases are to be accounted for by 
the catarrhal irritation conveyed to the sensitive nerves of the mucous 
membrane in the vicinity of the muscles affected. The irritation is thus 
conveyed to the motor nerves of the muscles in the catarrhal tract, and 
the latter, in an endeavor to eject the irritant, are thrown into a series of 
clonic spasms. 

Simultaneous Spasm in the Soft Falate. — In the vast majority of all the 
cases on record, this noise, whether voluntary or not, has been accompa- 
nied by a spasmodic elevation and retraction of the soft palate and some- 
times of other muscles of deglutition. 

Simultaneous Ticitchings Elsewhere. — In some instances the involuntary 
objective noise in the ear has been accomi)aoied by simultaneous ambi- 
lateral twitchings of the muscles of the brow, nose, and face, or with 
simultaneous spasms of the mylohyoid muscle, of the anterior bellj^ of 
the digastric, of the pterygoids, and in the brow on the same side. 



138 DISEASES OF THE EAR. 

There may be neuralgia in the brow and amyosthenia of the fingers on 
the side corresponding with the ear in which the noise is heard. 

The age of those thus affected varies from five to fifty years. Invol- 
untary objective noises in the ear, and the attendant symptoms already 
described, rarely occur on more than one side at a time. 

The mode of the occurrence of the involuntary snax)pings in the ear 
varies greatly. It may be too rapid to be counted (Schwartze), or isoch- 
ronous with the pulse, and so loud as to waken the patient at night 
(Boeck), or it may resemble the ticking of a watch, with pauses 
(Schwartze). 

The state of the hearing in an ear thus affected varies, being in some 
cases normal, in others noises occur in an ear already somewhat hard of 
hearing, while in some the hearing is momentarily affected, apparently 
by the altered tension which ensues in the tymj)anum with each spas- 
modic occurrence of the noise. 

Treatment. — The whole number of these cases is comparatively small 
and the individual experience in regard to them limited, so that our 
knowledge respecting the therapeutics of this variety of aural disease has 
been very meagre. So far as we can glean an opinion from what has 
been written by others concerning the treatment of these cases of clonic 
spasms, the induced current has effected the only apparent relief and 
cure (Schwartze, Politzer, and Boeck). This I have tried without any 
good effect. Since spontaneous perforation of the membrana tympani in 
a case observed by me was soon followed by entire cessation of the clonic 
spasm in the velum and elsewhere in the ear, and of the peculiar noises 
in the ear, I would recommend artificial i^erforation in any similar case, 
if speedy relief from the symptoms should be urgently required, or if 
they should not yield to treatment of the catarrh of the nasophajynx 
which so evidently underlies them as the true cause. The treatment the 
author has found beneficial in these spasms is one directed to the in- 
flamed nares and nasopharynx. 

SEQUELS OE CHRONIC CATARRH OF THE MIDDLE EAR. 

Just as there are diseases of the internal ear consequential to purulent 
diseases of the middle ear, so are there some affections of the internal ear 
manifestly due to catarrhal disease and consequent trophic vascular and 
nervous changes in the mucous membrane of the middle ear. 

The Internal Ear in Nephritis. — The nature of the labyrinth affections 
occurring in nephritis is difficult to estimate, as there are no autopsies on 
record. In such affections neither otoscoi)ic nor functional examination 
guides to a localization of the lesion. Increased arterial pressure, causing 
distention of the labyrinth vessels and paralysis of the sound-perceivers 
in the cochlea, has been suggested in explanation. Eosenstein has sug- 
gested the possibility of an oedema of the auditory tracts as the cause 
of defective hearing in nephritic i^atients. Others assume that transitory 



CHRONIC CATARRHAL OTITIS MEDIA. 139 

oedema causes temporary functional disturbances in parts of the brain. 
As oedema disappears, tinnitus aurium ceases and the hearing improves. 
Uraemia without oedema also causes deafness by involvement of the audi- 
tory nerve and central acoustic tracts. In some instances the ' ' loss of 
hearing, Avith the changed condition of the urine, is the only sign of an 
existing nephritis" (Morf). In fact, deafness is considered a symptom 
of chronic uraemia by some observers. 

According to Dieulafoy, ear symptoms are present in fifty per cent, 
of nephritic cases, slightly less frequent than eye symptoms. Sometimes 
the sudden, unexplainable ear symptoms are i\i^ first in a case of nephritis. 
In any instance of ear symptoms without well-known cause it is well to 
examine the urine. 

In regard to nephritic aifections of the internal ear, '■ ' there is a number 
of facts that indicate that we have to deal with the auditory nerve and its 
peripheral and central distribution" (Morf). According to Gradenigo, 
affections of the trunk of the auditory nerve are characterized by dimin- 
ished or lack of i)erception of the middle tones of the scale, while in 
labyrinth affections (perii^heral) perception of high tones is interfered 
with, while the middle and low tones are well heard. He also holds that 
in affections of the auditory nerve-trunk the electric irritability of the 
nerve is increased. In some instances it is possible that in chronic 
nephritis the auditory tracts become interrupted by interstitial hemor- 
hages. 

The Ear in JSInmps. — Profound trophic changes in the middle ear often 
occur rapidly in mumj^s, and extend apparently to the internal ear. It 
has seemed to me that protection of the body, keeping the patient in bed, 
as in a case of scarlatina, will ward off disease of the ear in mumps as 
care of the patient saves the kidneys in scarlatina. If deafness and 
vertigo do occur in mumps, treatment with pilocarpine, beginning with 
small doses and graduallj^ increasing, has been found efficient in pro- 
ducing entire cure. It may be necessary to keep u^) this treatment 
alternately with quinine for several months before entire recovery takes 
place. 

When the middle ear alone is affected after mumps, there is some 
hope of recovery of hearing, but there is none when the internal ear is 
attacked. Gruber maintains that bilateral deafness after mumps is 
incurable. 

The chronic vertigo that sometimes follows the otitis of mumps can 
be cured by surgical removal of the incus, the membrana, malleus, and 
stapes being left in i^osition. 

The Ear in Tabes. — Lerner ^ maintains that chronic deafness may ap- 
pear under two forms in tabes, — viz., (1) sclerosis of the middle ear, due 
to trophic disturbances in the fifth and glossopharyngeal nerves, and (2) 

^ Monatssch. f. Ohrenh., October, 1898. 



140 DISEASES OF THE EAR. 

nerve deafness, due to change in the nuclei, trunk and branches, and 
terminal parts of the auditory nerve. The disease is usually ambilateral. 

The Ear in Endocarditis. — Habermann^ reports a case of unilateral 
absolute and permanent deafness, due to an embolus in the stylomastoid 
artery, in a man of fifty -six, the subject of chronic endocarditis that had 
been productive of numerous peripheral embolisms. 

Traumatic Osteomyelitis and Consequent Ancemia ; Effects on the Internal 
Ear. — Functional and, finally, structural changes in the nervous appa- 
ratus of the ear may be induced by traumatic osteomyelitis and the 
anaemia consequent upon the necessary operations on the bone, as shown 
in a case reported by Wagenhauser. ^ 

Epilepsy from Ear Disease. — Yerdos^ maintains that in epilepsy ab aure 
Icesa there is a characteristic aura beginning in the auditory apparatus. 
In fact, every epileptic in whom the aura begins in the ear should be 
examined by an aurist, who in many instances will give great aid in the 
treatment. In some cases of manifestly aural epilepsy the aura does not 
start in the ear, but in one of the extremities ; later, however, it appears 
in one ear. This is a valuable diagnostic sign. 

Senile Changes. — The predominant senile change in the middle ear is 
atrophy of the bone, particularly in the ossicles (Ferreri). Osseous 
changes in the oval window also play an imj)ortant part in the deafness 
of old age (Politzer). The pathogenesis of senile deafness lies in athe- 
roma of the arteries, according to some observers, extending at last to 
the internal ear. 

Thyroid Gland. — Spear* asserts, as a result of his own observations, 
that the thyroid gland is ' ' the centre of a nervous system which controls, 
through connections with sympathetic ganglia and distant nerve-centres 
by a peculiar inhibition, all the blood-vessels and the centre of the circu- 
latory system, the heart itself." He has presented a number of cases 
tending to j)rove that frequently aural symptoms, tinnitus and deafness, 
accompanied by enlargement of the thyroid, are due to disease of this 
latter organ, and are relievable, more or less entirely, by hot- water appli- 
cations to the thyroid gland. 

I^erve Deafness and Hysterical Deafness. — '^]!^erve deafness," like 
^'hysterical deafness," due to primary internal ear disease, cannot be 
shown to exist. In all such asserted cases either a preceding or an 
attendant catarrhal affection of the middle ear can be shown to be the 
underlying cause of the aural symptoms, possibly modified in some cases 
by a neurotic diathesis. 

Ankylosis of the stapes enfeebles but does not abolish hearing. There- 



Annales des Mai. de 1' Oreille, January, 1899. 
Arch. f. Ohrenh., February 10, 1899. 
Annales des Mai. de F Oreille, March, 1896. 
Boston City Hospital Reports, 1896. 



CHRONIC CATARRHAL OTITIS MEDIA. 141 

fore, wlien the deafness is profound and the stapes ankylosed, the abolition 
of hearing is due to a lesion in the labyrinth. 

Functional impairment of the auditory centre occurs as a result of 
catarrhal deafness. This is analogous to the atrophy of the auditory 
centre supposed by some to occur in deaf-mutes. 

Effects of Quinine and Salicylic Acid. — Large doses of quinine and 
sodium salicylate produce both hypersemia and extravasation of blood in 
the middle and internal ears. Doses of from sixteen to thirty- two grains 
at a time, given to cats and dogs, produce death in from five to eight 
hours, and at the autopsj^ are found extravasations of blood and fluid in 
the labyrinth cavities sufficient to destroy hearing had the animal sur- 
vived the dose. Grunert^ has shown that such results in the ear are due 
to the poisonous effects of the drugs and not to strangulation, with symp- 
toms of which the animals experimented upon died. It is reasonable to 
suppose that relatively large and oft-repeated doses of these drugs given 
to man would readily produce organic changes in the middle and internal 
ears, resulting in i^ermanent destruction of hearing. 

Hysterical Mastoiditis. — So-called hysterical mastoiditis seems to be 
only neuralgia in neurotic women, made worse by their own manij^ula- 
tions of the external ear. 

1 Arch. f. Ohrenh., Xovember 30, 1S98. 



CHAPTEE XY. 

TREATMENT OF CHRONIC CATARRHAL OTITIS MEDIA. 

In treating chronic catarrh of the middle ear, the particular form pre- 
senting itself, either the moist or the dry, must be kept sharply in mind. 
Since chronic catarrhal otitis media is caused by chronic hypertrophic 
nasopharyngeal catarrh, and not by throat disease, the nasopharynx 
must receive the first attention, and the general health be improved, if 
impaired, as it generallj^ is. The treatment of the nares must be non- 
irritant, otherwise the ear disease will get worse. Oleaginous sprays 
are much better than watery sprays, since the former do not '^water- 
log" the tissues like the latter. Furthermore, oily sprays are considered 
more ef&cient germicides than water. 

Inflations of the tympana are not only valueless, but often injurious, 
as they but tend to force pathogenic germs into the middle ear, and shock 
the auditory nerve by impact on the fenestrse of the labyrinth, especially 
in the sclerotic form. 

Applications to the Nares, Nasopharynx, and Throat. — Medicated appli- 
cations to the nares, nasopharynx, and fauces are of great importance in 
the treatment of chronic aural catarrh. From what has been said else- 
where, it will be seen that from the nature of the origin of this disease 
in many instances, treatment of the parts just named would be indicated. 
In the vast majority of cases of chronic catarrh more benefit is derived 
from the proper treatment of the nares and nasopharynx than from 
direct medication of the tympanum. The latter is probably not as often 
reached by injections aimed at it through the Eustachian tube as is 
supposed, and, if reached by such substances, is more frequently injured 
than not. In every case of chronic aural catarrh the first lesion in the 
tympanum has been due to want of sufficient air in the cavity. This, of 
course, has come about by the occlusion, either temporary or permanent, 
of the Eustachian tube. Such being the case, the treatment must aim 
at the removal of this obstruction to ventilation of the tympanum and 
to its effects. The latter may have continued so long as to be irreme- 
diable, but the first aim in the treatment should be to restore the tube to 
its physical function as conveyer of air to the tympanum, and endeavor 
to check the advance of the disease. 

There are, however, some cases of chronic catarrh of the middle ear 

in which the Eustachian tube is found to be pervious both to natural and 

artificial inflation, and yet the hearing is much impaired. In these cases 

it will be found that the lining membrane of the tympanum has under- 

142 



TREATMENT OF CHRONIC CATARRHAL OTITIS MEDIA. 143 

gone a cliauge, generally sclerotic, and that the conductors of sound in 
the tympanic cavity have become stiffened by the chronic disease in the 
mucous membrane. 

Although the tube is found pervious in these cases when examined by 
the surgeon for the first time, there must have been a period in the history 
of the process when the tube was stopped up, and thus aided in bringing 
about the condition of the drum- cavity just mentioned. 

Let us first consider the local treatment of a case of hypertrophic or 
secretory nasopharyngo- aural catarrh. At the outset it must be borne in 
mind that, as a rule, no watery solutions must be used in this disease, 
oils being far preferable, and that the patient cannot carry out the treat- 
ment on himself, nor can it be applied for him at home by a friend or 
nurse. In addition to these injunctions, it must be stated that the nares 
are never to be cleansed or treated by syringing or lavage in any form. 
The nasal douche has done far more harm than good to the nares and the 
ears. 

Direct Medication of the Xares and Xasopharynx. — Direct medication of 
the nares and nasoi^harynx may be accomplished by instillations, by ap- 
plications conveyed into these parts on cotton twisted fast to the end of 
a cotton-holder, and by sprays and vapors. 

The hyi)ertrophied mucous membrane of the turbinated bones, espe- 
cially^ that of the inferior turbinated bone, may be touched with a 
mixture of iodine and glycerin in equal parts, or with an iodine mixture, 
comi:>osed of potassium iodide, thirty-six grains ; tincture of iodine, six 
grains ; distilled water or glycerin, one fluidounce. 

AYhen the anterior hypertrophies of the turbinated bones are to be 
touched, the nostrils must be dilated either by Kramer's speculum or by 
a short hard-rubber nasal speculum YQvy similar to a wide, short aural 
speculum. The latter remains in position by itself i the former must be 
held by the surgeon. The illumination should be by the forehead-mirror. 
The medication to be a^^iDlied is then couA^eyed to the anterior hyper- 
trophy^, or it may be carried along the entire length of the inferior turbi- 
nated bone to the i^osterior part of it, or to the posterior pharyngeal wall. 
Care should be taken not to touch the under edge of the turbinated bone 
nor the floor of the nose, as these parts are very sensitive. Hence the 
cotton-dossil must not be drij)ping nor too large. Neither must it be 
soaked, for in that case, if it is squeezed, excess of fluid will fall from it 
upon these sensitive parts as it is passed or pressed w^on the less sensi- 
tive side of the turbinated bone. In all forms of medication of the 
nares, nasopharynx. Eustachian tubes, and fauces the prime consideration 
is not to irritate. If the surgeon cannot cure, he must, at least, be careful 
to make no worse. Arrest disease, benefit the hearing if possible, but 
be careful not to retard nor to make worse chronic catarrhal processes in 
the nose and ear. I must refer to purely rhinological sources for direc- 
tions for treatment of i)Osterior hypertrophies of the turbinated bones, 



144 DISEASES OF THE EAR. 

adenoid growths, polypi of the nose, and major operations on the naso- 
pharynx. 

Sand- Atomizer and Sand- Nebulizer. — One of the most convenient, 
efficient, agreeable, and, at the same time, one of the safest ways of 
applying medication to the nares and nasopharynx is by means of the 
hand-atomizer or with a nebulizer. With this instrument the surgeon 
may convey into the diseased cavities of the nose and pharynx, in chronic 
aural catarrh, the spray of any desired mixture. 

If there is any accumulation of mucus which the patient is not able 
to remove by blowing his nose, the nares may be sprayed with Dobell's 
solution ; and this will supply the exception to the rule never to use 
watery solutions in the nares in chronic aural catari-h. If any other 
watery solution is to be used in the nares in such cases, it must be left to 
the expert to decide its nature and apply it. 

Whenever a watery spray is used it should be followed by an oily 
spray of fluid petrolatum and borax, five grains to one fluidounce, or 
of carbolic acid and fluid petrolatum, one grain to one fluidoUnce, espe- 
cially if the patient is soon to go into the open air, as the sheathing of the 
recently moistened mucous membrane with oil will i)revent taking cold. 

Excision of the Tonsils. — This operation I consider rarely, if ever, neces- 
sary for the relief of hardness of hearing or deafness, simply because the 
altered function of hearing is in no way dependent on the tonsillar en- 
largement. The larger tonsil is often on the side of the better ear, some- 
times on the side of a perfectly normal ear, and very often enlarged ton- 
sils are found in those with perfect hearing. 

Clipping iJie Uvula. — In some instances an elongated uvula keeps up a 
constant irritation of the fauces and posterior wall of the pharynx, thus 
contributing to an aggravation of an aural catarrh. All that is required 
in such cases is to clip ofl" the redundant mucous membrane, carefully avoid- 
ing ablation of the muscular part of this important appendage to the 
velum. A removal of such a fold of mucous membrane is generally 
stimulation sufficient to excite the rest of the uvula to contraction. The 
entire removal of the uvula is as reprehensible as it is common. Gargles 
alone will often contract the uvula. 

Gargles.— On^ of the simplest and best gargles in the pharyngitis 
which usually attends chronic aural catarrh is a saturated solution of 
potassium chlorate. Gargling not only aids in healing a pharyngitis, but 
it benefits the hearing by the gymnastic effect on the velum and the im- 
proved ventilation of the drum-cavity. 

The difficulty of diagnosticating the presence of fluid or even inspis- 
sated mucus in the tympanum, in cases of chronic catarrh, depends on 
several causes. The chief obstacle is, of course, the more or less altered 
condition of the membrana tympani. This may be so uniformly thick as 
to prevent seeing the delicate outlines of bubbles of mucus lying against 
its inner surface. If it is cicatrized at any point, the retained fluid will 



PLATE III. 



■WW 




Burnett's mounting of the Chevalier Jackson pneumatic masseur, fitted with the modified 
Siegle pneumatic otoscope. 



TREATMENT OF CHRONIC CATARRHAL OTITIS MEDIA. 145 

cause a bulging at the cicatrix almost invariably, especially after infla- 
tion ; but, if the membrane is uniformly thick, the mucus cannot make 
it bulge at any one point. If only one ear is affected, the examiner will 
be aided in his diagnosis by comparing the two ears. He will be guided 
hj the difference in position between the two membranse and also by the 
color. The membrana behind which there is retained fluid will bulge 
more than its fellow, if the drum-cavity be full of recent thick exuda- 
tion ; less so, if the matter in the drum be an old fluid accumulation. 
The color of the membrane is affected by the matter retained behind it. 
Instead of being bluish-steel in color, it becomes a tint of gray-amber. 
These are guiding-points in favor of x^aracentesis, even if bubbles in the 
fluid cannot be discerned behind the drum -head. 

If fluid is diagnosed behind the membrana tympani, it must be removed 
by i^aracentesis of the membrana. Inflations of the tymi)anum will not 
remove it. If secretions are allowed to remain in the catarrhal ear, they 
will become either gelatinized or organized into synechial bands. 

Inflation of the Ti/mjyana. — Having found that all forms of inflation of the 
tympana are valueless in the treatment of ear diseases, and that in many 
cases they are injurious, I have abandoned them for the past ten years, 
and have substituted in their place i:)neumomassage of the external audi- 
tory canal and mediatelj' the membrana tymj)ani and ossicula. 

Fneumomassage of the External Auditory Canal compared icith Inflation 
of the Tympanum. — Pneumomassage— alternate condensation and rarefac- 
tion of the air in the external auditory canal — may be effected in two ways, 
— viz., either by means of Siegle's i^neumatic ear-speculum (Fig. 59), 
operated by the surgeon's mouth, or by means of a small air-pump or 
syringe, run b}" a miniature electromotor, as in the verj' useful Chevalier 
Jackson instrument (Plate III.). 

With the Siegle instrument, operated by suction from the surgeon's 
mouth, a more powerful rarefoction can be applied to the canal than with 
the Jackson instrument, and the membrana tymi^ani thus drawn outward 
and traction made u^dou the tensor tympani, and kept up as desired, as 
with no other ear-instrument at our command. In fact, the chief thera- 
peutic usefulness of the Siegle instrument lies in its ability to produce 
and maintain rarefaction of the air in the auditory canal and consequent 
pneumatic traction upon the membrana tymjDani and its tensor. If it be 
desired, the circulation in the manubrial plexus of vessels, in the vessels 
of the membrana tymi^ani, and even in the drum-cavity can be quick- 
ened by rarefaction of the air in the canal thus evoked much more rai)idly 
than with the Jackson air-pump. 

Also a very powerful condensation of the air in the auditory canal 
can be created by the Siegle instrument when operated by the mouth of 
the surgeon. When the motive force lies in the surgeon's mouth, in the 
employment of this instrument, it has a wider and more quickly vary- 
ing range of application than the Jackson instrument. 

10 



146 DISEASES OF THE EAK. 

With tlie latter instrument, in which the Siegle pneumatic specu- 
lum is operated by the air-pump, very gentle and excellent periodic 
pneumomassage can be applied to the membrana tympani and malleus, 
and mediately to the incus and stapes. Little or no blushing of the 
manubrial plexus takes place under the use of this instrument, if applied 
for only from thirty to forty seconds, and at a rate of two strokes of the 
piston a second. Good effects are obtainable in thirty seconds, as a rule, 
while its application for sixty seconds may be uncomfortable or even 
painful to the patient. 

Either of the above-mentioned forms of rarefaction and condensation 
of the air in the external ear can be applied to one ear at a time, a great 
advantage over all forms of tympanic inflation excepting catheterization. 
In the employment of the various forms of gentle pneumomassage of the 
external auditory canal, the force is exercised directly upon the mem- 
brana tympani only. IN'o sound is conveyed to the ear in this procedure, 
and therefore the auditory apparatus escapes the great dangers existing 
in all forms of phonomassage or vibromassage, which sooner or later 
impair the auditory nerve. In fact, they produce a form of ' ^ boiler- 
maker' s deafness." 

There are several forms of inflation of the tympana, — viz., the so- 
called air-douche, catheterization, Yalsalvian autoinflation, and inflation 
by means of a nebulizer. All of these, excepting catheterization, are ap- 
plied, whether desired or not, to both ears ; nebulizer inflation has the 
advantage of conveying medicated air to the tympana. Yalsalvian auto- 
inflation has the very great disadvantage of producing congestion of the 
head and auditory apparatus in addition to other disadvantages accruing 
to the ears by its use. All forms of inflation possess the great disadvan- 
tage of being liable to force pathogenic matter from the nasopharynx into 
the naturally aseptic middle ear. This is especially true of the catheter, 
as in its passage through the nares and nasopharynx it takes up septic 
matter from these cavities and conveys it at least to the mouth of the Eu- 
stachian tube, or takes up at the latter point septic matter and furthers its 
advance up the tube and to the drum-cavity as soon as the air-bag is 
blown into the catheter by the surgeon. All forms of inflation of the 
drum- cavity are more or less septic procedures, but catheterization is 
most so. It is fortunate that it is applied to only one Eustachian tube at 
a time. Nebulizer inflation is the least harmful, as it is very gentle, and 
is supposed always to convey an aseptic vapor to the Eustachian tube 
and middle ear when it inflates the latter. 

Inflation of the tympana is rarely, if ever, needed 5 certainly not 
nearly as often as is generally supposed, because entire want of air in the 
drum- cavity is among the rarest of occurrences, on account of the so-called 
^'safety-tube" formed by the under surface of the thick, sharply crooked 
cartilaginous roof of the Eustachian tube, as pointed out thirty years ago 
by Eiidinger, of Munich (pages 50, 51). This ^'safety-tube" in the 



TREATMENT OF CHRONIC CATARRHAL OTITIS MEDIA. 147 

Eustachian tube prevents the occurrence of a vacuum in the drum-cavity 
and renders any form of Inflation usually unnecessary. When inflation 
of the tympana is performed, it is more or less of a sudden shock to the 
middle ear, and especially to the nerve of hearing. The sudden entrance 
of air, via the Eustachian tube, into the t^^mpanic cavity tends to force 
the membrana tympani and malleus outward and the incus, stapes, and 
membrane of the round window inward. 'Now, such a procedure is surely 
contraindicated when the sta^DCS is already unduly imi)acted in the oval 
window, as in catarrhal processes in the drum-cavitj'. A force thus ex- 
erted upon the stapes and the round- window membrane at the same mo- 
ment is especially prejudicial to the welfare of the auditory nerve in the 
labyrinth, because the recoil of the labyrinth fluid from the impaction of 
the stapes is prevented hj the simultaneous inward pressure of the mem- 
brane of the round window by the inflation, and the usual yielding and 
comj)ensatory function of this round-window^ membrane, in imj)action of 
the stapes, is temporarily abrogated. Direct violence by compression 
may be thus offered to the labyrinth of both ears, whether normal or dis- 
eased, and it can readily be understood why inflation is usually disagree- 
able and sometimes i^ainful to the patient, and also why tinnitus and 
vertigo are often made worse by it instead of being relieved. 

Pneumatic Traction on the Tensor Tympani indicated in Chronic Catarrh 
of the Middle Ear. — The tensor tymi)ani tendon is covered by a fibrous 
sheath, considered by Helmholtz to be a continuation of the periosteum 
lining the muscular canal in the bony portion of the Eustachian tube, 
from which it arises. 

We can thus explain the early participation of this muscle and tendon 
in catarrhal and arthritic i^rocesses in the nasopharnyx, Eustachian tube, 
and middle ear. Therefore, we can understand why one of the earliest 
sj^mptoms of chronic catarrhal otitis media is contraction of this muscle 
and its tendon, with consequent retraction of the membrana tympani. 
With such retraction of the membrana tympani there are usually asso- 
ciated varying degrees of tinnitus aurium and imj)aired hearing, at first 
directly traceable, largely, if not entirely, to the retraction of the mem- 
brana and ossicles. Later on, if this retraction is not overcome, there are 
vascular changes in the ossicles and tympanic walls, with ankylosis of the 
ossicles and firmer imj^action of the stapes in the oval window. 

In such cases, in addition to treatment of the nasopharynx, it has been 
customary to inflate the tympana in various ways. But no form of infla- 
tion ever im^^roves the hearing, relieves the tinnitus, and gives a sensa- 
tion of openness to the ear equally as well, as agreeably, or as promptly 
as maintained rarefaction, or gentle, alternate rarefaction and condensa- 
tion of the air in the external auditory canal by means of Siegle's pneu- 
matic speculum applied to one ear at a time. 

Pneumomassage applied to the external auditory canal and membrana 
tympani, and mediately to the ossicles of hearing, in both acute and 



148 DISEASES OF THE EAR. 

chronic catarrhal processes in the middle ear, is more efficient, less of a 
shock to the auditory nerve, more agreeable to the patient than inflation, 
and entirely free from sepsis, Tvhereas inflation is not. Inflation of the 
tympana, being very rarely necessary as a means of forcing air into the 
middle ears, the latter being very seldom in need of it, it is fair to con- 
clude that inflation of the tympana, as it must be applied to both ears, 
whether desired or not, is usually contraindicated in aural diseases. 

On the other hand, as drawing the membrana tympani and malleus 
outward and traction on the tensor tympani and restoration of the nor- 
mal isolation of the auditory ossicles are desired without any shock to the 
structures upon the inner wall of the drum-cavity, and as these can be so 
safely effected by pneumatic rarefaction of the air in the auditory canal, 
pneumomassage is indicated for these purposes. In fact, some form of 
pneumomassage of the external ear has almost entirely superseded the 
use of all forms of inflation of the tymi)anum in my hands for the past 
ten years. 

Excellent results are often produced by gentle treatment of chronic 
catarrhal otitis media as outlined above, continued two or three times 
weekly for several months, whereas under vigorous treatment by strong 
sprays, j)/io/iomassage, and numerous inflations of and local applications to 
the nasopharynx and middle ear, all the symptoms — tinnitus, deafness, 
and vertigo — increase. In no case of chronic catarrh of the middle ear 
will applications to the external ear and membrana do anything but 
harm. 

If, in spite of rational, conservative, non- irritant treatment of the 
nasopharynx, and gentle pneumomassage of the membrana, the ear symp- 
toms grow worse, resort may be had to removal of the incus. The result- 
ant overcoming of the retraction of the chain of ossicles, and consequent 
liberation of the stapes, will be followed by diminution and final cessation 
of the tinnitus and vertigo, and in some cases by improved hearing. 

Tympanotomy and Removal of the Incus seem to arrest Progressive Hard- 
ness of Searing. — It ^ill be admitted by all aurists that one of the earliest 
events in chronic progressive deafness is retraction of the membrana 
tympani and the chain of auditory ossicles, with consequent compression 
of the labyrinth-fluid. This retraction of the conductors and compres- 
sion of the labyrinth-fluid do not reach their height at once, but by 
degrees, and hence the gradual onset of the typical aural symptoms, tin- 
nitus, dulness of hearing, and vertigo arising from the progressive physi- 
cal changes in the drum-cavity. As the physical changes in the con- 
ductors increase and become permanent, organic changes occur in the 
labyrinth. It is admitted that loss of hearing in such cases is first due 
to impaired mobility of the stapes and the increased intralabyrinth press- 
ure induced by impaction of the stapes. All operations and manoeuvres 
for the relief of chronic catarrhal deafness have in view liberation of the 
stapes and diminution of intralabyrinth pressure. The retardation of 



TREATMENT OF CHRONIC CATARRHAL OTITIS MEDIA. 149 

this progressive loss of function and the restoration of hearing while the 
pathologic changes are limited to the drum-cavity have ever been and 
are still the greatest tasks of aurists. The aurist knows only too well 
that his chances of arresting and curing progressive hardness of hearing 
exist only while the disease is limited to the drum-cavity. Xo treatment 
can overcome organic changes in the labyrinth. 

When excision of the entire membrana tympani with the malleus and 
incus was first proposed as a means of relief in chronic catarrhal deaf- 
ness, one of the first questions asked about its effects was whether it would 
check the progress of the deafness even if it did not improve the hearing. 
Pretty soon a negative answer was given to this question. In fact, it 
neither permanently improved the hearing nor checked its progressive 
loss, as it was always followed by inflammatory reaction. About eight 
years ago I su])stituted tympanotomy and removal of the incus only (the 
membraua, malleus, and stapes being left in situ) for total excision of the 
membrana tymi)ani for the relief of chronic catarrhal deafness, tinnitus, 
and vertigo. This oi)eration — far more difficult than total excision of the 
membrana and removal of the ossicles — is, according to my experience, 
unattended with reaction, improves the hearing to some extent in a few 
cases, does not make it worse in any, and relieves the tinnitus and ver- 
tigo when dependent upon catarrhal retraction of the membrana and 
imi^action of the stapes. These results of the removal of only the incus 
became manifest at once, but whether or not this operation would have 
a deterrent effect on tlie progress of the deafness in the ear operated upon, 
and perhaps by synergy upon the opposite ear, could not be answered at 
once. 

The number of cases of progressive hardness of hearing I have oper- 
ated ui^on by tym^ianotomy and removal of the incus up to the present 
time is sixty-one. Most of these patients heard but very little at the time 
they were operated upon. Little or no improvement in hearing took 
place, but none have been made worse, and this latter fact is the most 
important one established regarding the hearing in most cases. In fact, 
the operations have been performed chiefly with the expectation of re- 
lieving tinnitus and ear-vertigo rather than the deafness, so advanced has 
the latter been. Tinnitus and vertigo have been relieved or banished in 
all cases ; the hearing has remained unaltered or slightly improved in all 
cases. It would seem, therefore, to at least check the progress of the deaf- 
ness. I have already stated elsewhere ^ that the cessation of tinnitus and 
vertigo may not be complete and permanent for six months after the 
removal of the incus and liberation of the stapes. After the lapse of six 
years since tymj^anotomy and the removal of the incus in one case of not 
profound deafness that I have observed at times ever since the opera- 
tion, I am now able to report that in his case the removal of the incus 

^ Pennsylvania Medical Magazine, February, 1898. 



150 DISEASES OF THE EAR. 

has had a deterrent effect upon the progressive hardness of hearing, not 
only in the ear from which the incus was taken in December, 1892, but 
apparently upon the other ear not operated upon. The good result in 
this instance I attribute to the fact that I operated before the hearing 
had sunk to less than a foot. 

I think that the course to be pursued in cases of progressive hardness 
of hearing will be one that will arrest progress rather than one that can 
restore lost hearing. The latter object is apparently unattainable after 
the hearing has sunk to half its normal quantity. 

Let us suppose normal hearing to be represented by 100, and let us 
imagine that a case of progressive hardness of hearing x)resents itself, 
with a hearing distance of 50 in one ear and a hearing distance of 75 
in the other ear. Every aurist knows that the tendency of such a case 
is to fall in hearing to zero, or very near it, in both ears. It is to be 
hoped that it can soon be demonstrated that to remove only the incus 
from the deafer ear, through an incision in the posterior segment of the 
membrana tympani, the latter, the malleus, and the stapes being left 
in normal position, though it may cause the ear oi^erated upon to fall to 
20 or 25 in the hypothetical scale of hearing, will arrest the deafness 
at that point, and by synergy prevent the other ear from progressing far- 
ther into deafness. It would seem that the mistake of aural surgeons 
has been in trying to restore lost hearing in such cases, instead of devising 
methods of arresting progressive deafness. We should operate while 
there is hearing to save. 

Chronic Ear-Yertigo : Its Mechanism and Surgical Treatment. — Chronic 
ear-vertigo, sometimes called Meniere's disease, consisting in paroxysmal 
attacks of vertigo, is due to chronic catarrhal disease in the tympanic 
cavitj\ This latter malady tends to sclerosis of the mucous membrane of 
the cavity, rigidity of the membrane of the round window, retraction and 
stiffening of the ossicles of hearing, and a consequent impaction of the 
stapes in the oval window of the vestibule. This latter event, by iDressure 
upon the labyrinth- fluid and consequent compression of the endolym]3h 
about the nerve terminals in the amj)ullse of the semicircular canals, 
leads to the reflex phenomenon termed ear-vertigo. 

In order to understand the mechanism of ear- vertigo, one must recall 
the anatomy of the middle and internal ears. 

1. The Labyrinth- Fluid. — The labyrinth-fluid is composed of two sys- 
tems, — viz., the endolymph, that which fills the interior of the mem- 
branous labyrinth, and the perilymph, filling the cavity of the bony 
labyrinth in which the membranous labyrinth is suspended. The endo- 
lymph, according to Hasse, of Wiirzburg, comes from an epicerebral 
lymph- cavity, being conveyed by the so-called aquaeductus vestibuli to 
the cavity of the membranous labyrinth (Fig. 75, 4). Every increased 
or diminished pressure in the cerebrospinal fluid in the subarachnoid 
cavity will make itself felt through the aquseductus vestibuli in the in- 



TREATMENT OF CHEOXIC CATARRHAL OTITIS MEDIA. 



151 



terior of the membranous labyrinth. The same authority shows that the 
perilymph is poured into the labyrinth from the subarachnoid space 
through the foramina acustica, and leaves the labyrinth by means of the 
aquseductus cochleae (Fig. 75, 3). In fact, the perilymphatic cavity is 
inserted into the lymxDhatic tract of all vertebrates ; and, being in con- 
nection with the subarachnoid space, it is seen how changes of any kind 
in the cerebrospinal fluid can be communicated to the perilymph and 
thence to the various i)arts of the membranous labyi^inth. Especially 
can we understand how easily intralabyrinth-fluid pressure may be 
increased either from the cranial side through the aqueducts or the 
tympanic side through impaction of the stapes in the oval window, the 
semicircular canals thus irritated, and vertigo ensue. 

Fig. 75. 




Cast of the left temporal bone after corrosion of the osseous tissue ; the pneumatic cells cover 
the entire labyrinth excepting at the outer ends of the aqueducts, the internal auditory canal, and 
the upper curve of the superior semicircular canal. (Siebenmann.) 1, superior semicircular canal; 
2, internal auditory meatus ; entrance of auditory nerve ; 8, aquseductus cochlear ; 4, aquaeductus ves- 
tibuli. 



If in a i)roperly prepared normal auditoiy apparatus in a cadaver 
sound is conveyed from an organ-pipe into the external ear, the vibra- 
tions of the membrana, ossicles, and round-window membrane can be 
seen and measured, as I have shown in my physiological acoustic experi- 
ments in Helmholtz's laboratory in 1871-72. If the auditory apparatus 
has been so prepared as to enable the experimenter to convey water to 
the labyrinth from the side of the cranial cavity and thus increase the 
intralabyrinth i)ressure, while the sound vibrations of the ossicles and 
round-window membrane are going on, he will soon perceive that the 
intralabyrinth distention or engorgement thus brought about by the in- 
troduction of water into the internal ear will force the stapes and round- 



152 



DISEASES OF THE EAK. 



window membrane tightly outward and cause their vibrations to cease, 
while the vibrations of the membrana, malleus, and incus continue. 
Thus an idea may be gained of what takes place in an engorgement of 
the internal ear from influx of lymph from the cranial cavity, or from 
congestion of the former. This outward fixation of the stapes in such 
instances might be less if the bonelet were not pushed outward against 
the incus and its fixation thus further augmented. Outward distention 
of the round- window membrane could be overcome by puncturing it j 
but this I have never done. 

2. Bole of the Middle and Interned Ears in the 2Iechanism of Ear- 
Yertigo. — My meaning as to the mechanism of chronic ear- vertigo may 
be made clearer by a consideration of Fig. 76. Thus, if the stapes S is 
impacted into the oval window O.W., its foot-plate will press upon the 

fluid in the vestibule Y, and if a 
recoil from this pressure cannot 
be obtained by the bulging of the 
membrane of the round window 
E.W. towards the tympanic cav- 
ity, the lymph in Y, as well as 
in the entire labyrinth, is unduly 
compressed, the semicircular ca- 
nals irritated, and ear-vertigo re- 
sults. Or, if in any sudden and 
copious influx of lymph from the 
cranial cavity into the labyrinth, 
or in an increased vascularity 
of the labyrinth, a compensating 
recoil from such intralabyrinth 
pressure cannot be obtained at 
E.W., and also at S, as in a nor- 
mal ear, the semicircular canals 
are unduly com^^ressed and ear- 
vertigo is evoked. As is well 
known, both of these recoil points 
in 



o.w. 




Partly diagrammatic vertical section of the left 
auditory apparatus, in front of malleus and oval 
window, running through the vestibule and promon- 
tory, and viewed from in front. (Modified from 
Siebenmann.) H, hammer ; I, incus ; S, stapes ; M.T., 
membrana tympani ; V, vestibule ; O.W., oval win- 
dow ; R.W., round window ; T, tendon of the tensor 
tympani. 



the fenestrce become more or 

less unyielding in the later stages 

of chronic catarrh of the middle 

ear, when paroxysms of ear- vertigo are likely to be added to the already 

profound deafness and tinnitus. 

Symptoms. — As the great majority of cases of chronic ear- vertigo occur 
in chronic sclerotic otitis media, let us first consider the symptoms of ear- 
vertigo as they occur in this form of tympanic disease. Usually only one 
ear (the worse) is the cause of ear- vertigo, though both ears may be af- 
fected with so-called chronic catarrhal otitis media. The more affected 
ear (the one causing the ear- vertigo) is always prof oundly deaf and may 



THEATMEXT OF CHRONIC CATARRHAL OTITIS MEDIA. 153 

be the seat of distressing tinnitus. In any case chronic ear-vertigo is 
(chronologically) the last among the lesions of chronic catarrh of the 
middle ear. It is manifest from this that the internal ear can lose 
its hearing function before its equilibrating function. In an ordinary 
case of ear-vertigo from chronic tympanic catarrh, the patient in the first 
attack is seized with a sudden and to him unaccountable vertigo, usually 
attended with an increase of tinnitus in the implicated ear. The attack 
may last from a few minutes to half an hour. The patient may be obliged 
to take hold of something for support, or to sit or lie down. Xausea may 
be present in the early attacks if the vertigo continues as long as fifteen 
minutes, but, as a rule, nausea and vomiting do not occur in the first 
paroxysms of this disease. When the seizui^es become more frequent, 
more severe, and longer in duration, nausea and vomiting may be very 
intense, and result in a form of collapse with pallid foce and clammy sur- 
face, but without loss of consciousness. The fact that the ]Datient does not 
lose consciousness from ear- vertigo serves as the great differential guide 
in diagnosis between ear- vertigo and apoplexy and epilepsy, with both 
of which it is often confounded at first. The apparent motion in ear- 
vertigo is generally towards the affected ear, in which direction the 
patient tends to fall. TThen both ears are the cause of ear- vertigo, the 
patient is entirely unable to walk, and sits down whenever he is attacked, 
even in the street. These phenomena have been termed Meniere's symp- 
toms or disease. 

The first attack of ear- vertigo is usually comparatively light, and 
generally attributed to stomachic derangement and treated as such. This 
first attack may not be followed b}' another for weeks or even months. 
Then a more severe attack comes on, which is followed in a week or two 
by another. At last the attacks may occur every week or everj^ day. 
The patient now fears to leave the house, unless accompanied by an at- 
tendant, and is forced by this quasi-agoraphobia to give up any regular 
duties outside of his house. Even in such cases the true cause of the ear- 
vertigo is usually overlooked and the symptoms attributed to other influ- 
ences. As the diagnosis is defective, the treatment not only does no 
good, but rather harm, if depletive, as it often is when ' ' biliousness' ' or 
' ^ ax^oi)lexy* ' is deemed causative of the vertigo. Finally, something 
draws attention to the ear as a possible factor in the production of the 
vertigo. Examination now reveals the fact that the patient is a victim 
of chronic ear-vertigo, most commonly of that form found in the late 
stages of chronic sclerotic otitis media. Deafness and tinnitus are found 
to have been present for a long time, to which within a few months, or 
even a year, there has been added the most distressing symptom of all, — 
viz., a tendency to frequent attacks of ear- vertigo. These may be so 
severe and so frequent as to keep the patient, especially if a woman, in 
bed for weeks at a time. If the patient be a man, he is rendered unfit for 
leaving the house alone and attending to his daily vocation. He be- 



154 DISEASES OF THE EAR. 

comes low-spirited, his general health fails, aud his will-power becomes 
impaired. If the patient persists in leaving the house and in trying to 
work, he is liable to be attacked at any time by severe vertigo, nausea, and 
vomiting, his face becoming very pale and bathed in clammy sweat. At 
this point he will reel and fall if not supx^orted, but there will be no loss 
of consciousness. He becomes helpless and must be carried home. I recall 
a case of this nature in which the patientj'li man of forty, was attacked 
while ''on 'change," and was brought in semi-collapse in a carriage to my 
of&ce for relief. 

Memhrana Tym])ani, — If the membrana tympani of a patient affected 
with chronic catarrhal ear- vertigo be examined, it will be found to present 
the usual appearance of the drum-head in chronic catarrhal deafness, — 
viz., opacity, thickening, and retraction. The retraction of the mem- 
brana is so great as to draw the malleus upward and backward^ carrying 
the membrana with it. In most of such cases the incudo-stapedial joint 
can be seen through the upper posterior quadrant of the drum-membrane. 
The examiner then sees in the retraction of the membrane and ossicles the 
mechanical cause of the ear-vertigo. The retracted chain of bonelets, by 
pressing the stapes inward into the oval window and holding it there in 
a condition of undue retraction upon the vestibule and its fluid, compro- 
mises the latter space and compresses the labyrinth-fluid upon the am- 
pullar nerves in the semicircular canals, and ear-vertigo is evoked. 

Ear- vertigo is not constant, however, because varying conditions of 
relieved tension in the middle ear and the chain of ossicles on the outer 
side of the stapes, and also similar variations in the labyrinth-lymph on 
the inner surface of the stapes foot-plate in the oval window, suspend 
temporarily the compression of the ampullar nerves, and the patient is 
temporarily free from vertigo. 

The stapes, however, being permanently in a state of undue impaction 
in the oval window, it requires but little additional inward pressure of 
the stapes from the tympanic side or increased flow of lymph into the 
labyrinth to exert undue compression of the endolymph in the already 
compromised labyrinth space and irritative pressure upon the ampullar 
nerves, followed by an attack of ear-vertigo. Varying conditions in the 
health and circulation of the lymph or blood of the i3atient are sufficient 
to evoke these attacks in one in whom the drum-cavity is already diseased 
and the labyrinth space com]3romised, — i.e.j contracted by the chronic 
impaction of the foot-plate of the stapes in the oval window. In a normal 
state undue inward pressure of the stapes into the oval window is com- 
pensated by a yielding of the round-window membrane towards the drum- 
cavity. In a normal auditory apparatus any undue increase in the flow 
of lymph towards the labyrinth, including, of course, the vestibule, is 
compensated by the recession of the stapes outward towards the tympanic 
cavity and probably by a similar recession on the part of the membrane 
of the round window. But if the stapes in the oval window and the 



TREATMEXT OF CHRONIC CATARRHAL OTITIS MEDIA. 155 

membrane of the round window are rendered abnormally rigid^ as they 
often are by chronic catarrhal otitis media, compensatory recession at 
these two points to intralabyrinth pressure is impeded, the intralabyrinth 
space is thus easily engorged by an inflow of lymph or hj increased vas- 
cularity, its fluid is compressed upon the ampulliie, and ear- vertigo is pro- 
duced in a purely mechanical way, depending largely upon retraction of 
the tensor tympani and the ossicles in chronic catarrhal otitis media. 

Ear-Vertigo in Chronic Purulent Otitis 2Iedia. — Ear-vertigo sometimes 
occurs in the subjects of chronic purulent otitis media. In these cases, 
too, the retraction and impaction of the stapes by the superposed and 
enlarged malleus and incus usually play the chief part in producing 
vertigo, for the malleus and incus in such cases are often covered with 
swollen and granulating mucous membrane, and bound firmly by synechioe 
to each other and the inner tympanic wall and thus are made to press 
very forcibly upon the stapes. In these suppurative cases the blood- 
vessels of the mucous membrane of the drum- cavity are always deeply 
engorged, and as these vessels are intimately connected with the blood- 
vessels of the labyrinth, it is easy to see how the latter may become un- 
duly engorged and excessive intralabyrinth pressure thus induced, result- 
ing in ear- vertigo. Irritation and engorgement of the labyrinth, with 
resultant vertigo and nystagmus, in purulent otitis may also be due to 
direct transmission of inflammation through a carious opening from the 
drum-cavity into the horizontal semicircular canal or at some other point 
in the outer wall of the labyrinth. Though the mode of production of 
the ear- vertigo in such cases is somewhat different from that in chronic 
catarrhal otitis, the mechanism is the same, — viz., a mechanical pressure 
compromising the labyrinth sj)ace and compressing the ampullar nerves 
in the semicircular canals. 

Treatment. — The cause of chronic ear- vertigo being a mechanical one, 
consisting chiefly in impaction of the stapes in the oval window, removal 
of this retractive force and liberation of the stapes should cure the dis- 
ease. Consequently, many years ago I devised an operation consisting in 
surgical removal of the incus in cases of ear-vertigo originating from 
chronic catarrhal otitis. The removal of the incus breaks the retractive 
force of the tensor tymj^ani and malleus exerted through the incus ux)on 
the stai^es, and the latter bonelet is liberated. 

In chronic purulent cases it is necessary to excise the remnants of the 
diseased membrana and the malleus and incus, with their synechial 
bands, in order to liberate the stapes. This operation in such cases, sup- 
plemented by local treatment of the purulent drum- cavity, is followed by 
cessation of the vertiginous attacks and cure of the chronic purulency. 
Thus, excision of the diseased ossicles in such cases leads to curing the 
chronic purulency and acts as a prophylaxis of antrum and mastoid disease. 

Ojye ration. — The patient is etherized (local ansesthesia by cocaine being 
both inefficient and toxic, according to my experience) and the external 



156 



DISEASES OF THE EAE. 



auditory canal and the membrana sterilized by a solution of mercuric 
bichloride (1 to 5000) or one of formalin (1 to 1000). Then the auditory 
canal and membrana tympani are illuminated by means of an electric 
light held on the forehead and run by a small portable storage battery, 
made for the purj^ose of clinical illumination (Fig. 55). 

Where the membrana is intact, as it is in a case of chronic ear-vertigo 
due to chronic catarrhal otitis media, the initial incision is made with a 
delicate knife (Fig. 77, 2), beginning close behind the short process of the 
malleus and following closely the periphery backward and downward 
until reaching a point below the line drawn horizontally through the 
umbo of the membrana. This cut is followed by little or no bleeding, 
as a rule. The flap thus made should be pushed inward towards the 
promontory by means of a j)robe armed with a small dossil of sterilized 
cotton. If there is no bleeding, the incus-stapes joint is seen as soon as 
the flap of the membrana is pushed aside. If there is bleeding, it must 
be mopped away with sterilized mops on a cotton-holder. 

The long limb of the incus being now in plain sight, it should be 
gently disarticulated from the stapes by drawing the former outward and 
downward by means of an incus hook-knife (Fig. 77, 4) passed behind it. 
When this is done the long limb of the incus should be grasped by 
special forceps (Fig. 74) and drawn very cautiously downward and out- 
ward into the auditory canal, and then removed entirely from the ear. 
When this is accomplished the operation is finished. The slight bleed- 
ing that sometimes occurs in the chronic catarrhal cases 
requires no attention. The meatus should be stopped 
with sterilized cotton and the ear let alone for twenty - 
four or even forty -eight hours, unless the cotton in the 
meatus gets moist with blood or serum. If this occur 
the cotton should be removed and dry cotton inserted. 
There is to be no after-treatment in such cases, as all 
is accomplished when the incus is removed. As a 
rule, there is no reaction, and the wound in the mem- 
brana heals by first intention. Sometimes a slight re- 
action has occurred, shown by a little pain and some 
muco-purulent discharge ; but this is healed in a few 
days by simply mopping the ear with sterilized cotton 
and a solution of formalin (1 to 1000), and the inflammation has never 
had any bad effect upon the result of the removal of the incus in check- 
ing the vertiginous attacks. A serious reaction I have never encountered 
after the operation, neither in the chronic catarrhal nor in the chronic 
purulent class. 

The mode of operation in the purulent cases is different from that in 
the chronic catarrhal cases with intact drum-membrane. In the former the 
membrana is already perforated and the ossicles, if still present, plainly 
visible in most instances. The incus should be detached and removed 



Fig. 77. 

2 3 



1^ 



Instruments for ossicu 
lectomy. 



TREATME>'T OF CHRONIC CATARRHAL OTITIS MEDIA. 157 

first, and then the remnant of the diseased membrana and malleus should 
be completely excised. Hemorrhage in such cases is always relatively 
great, and delays the operation, as the field of operation requires constant 
and comi^lete mopping before the surgeon can proceed. After the oper- 
ation the ear requires syringing with a bichloride solution (1 to 5000), 
but the ear should not be stopi^ed with cotton but allowed to discharge. 
The subsequent treatment must be that indicated in a case of chronic -pn- 
rulent otitis media. I have performed this oi)eration in its two forms 
named above in twenty-seven cases of chronic ear-vertigo, mostly in 
chronic catarrhal otitides, and in no instance has it failed to give relief, and 
I know of no other kind of equally successful treatment of chronic aural 
vertigo (Meniere's disease). In two instances entire and i^rompt relief 
from ear-vertigo of over a year's duration folloicing mumps has been 
afforded by the surgical removal of the incus as described above. 

Pilocarpine gives no relief in genuine ear- vertigo due to changes i)ri- 
marily in the ossicles and the fenestrse in the middle ear. In fact, no 
drug can cure a true ear- vertigo originating in middle-ear disease that 
finallj^ implicates the internal ear. Trousseau long ago pointed out the 
fact that vertigo ah aure Iccsa was of frequent occurrence ; but he failed to 
relieve it by drugs. The only relief to be afforded in chronic ear-vertigo 
is by surgical liberation of the stapes ; not by destruction of the internal 
ear, neither by large doses of quinine (Trousseau) nor by surgical means. 

Filocarpine injections in labj'rinthitis are rarely of benefit. If no result 
is obtained after three or four injections, it is best to abandon this treat- 
ment. In deafness accompanying mj'xoedema the internal administration 
of thyroid gland has given good res alts (Cresswell Baber). Pilocarpine 
is contraindicated in functional diseases of the ear ; therefore it is impor- 
tant to make a careful differential diagnosis between organic and func- 
tional diseases of the ear. If pilocarpine ever does good, it must be given 
in the early stages of an otitis interna. Iiiflations make the aural disease 
worse. 

In syphilis of the ear^ intranasal sprays of Yan Swieten's solution have 
been employed by Eutten, and Delie and Gelle administered the iodides 
in wine, mixed with tannic acid to prevent intolerance. In all instances 
of chronic ear disease inflation will do harm by shock. 



CHAPTEE XYI. 

ACUTE PURULENT OTITIS MEDIA. 

Acute catarrhal otitis media, instead of undergoing resolution, 
may pass into acute purulent otitis media, induced by the passage of 
pathogenic germs from the nasopharynx into the middle ear. 

Bacteriology. — It has been shown by the investigations of Lowenberg, 
Frankel, Simmonds, Zaufal, and many others that genuine primarj^ acute 
otitis media may be excited by the following germs : 1, the pneumococcus 
of Frankel ; 2, the streptococcus pyogenes 5 3, the pyogenous staphylo- 
cocci ; 4, the pneumobacillus of Friedliinder ; 5, the bacillus pyocyaneus ; 
6, the meningococcus intracellularis of Weichselbaum- Jaeger (as in cases 
exhibiting this germ the aural suppuration was the primary disease from 
which the cerebrospinal meningitis originated) ; 7, the actinomyces. The 
chief producers, however, of primary acute otitides are the pneumococ- 
cus of Frankel, the streptococci, and the staphylococci. The other germs 
occur only exceptionally/ 

Etiology of Acute Fur ident Otitis Media. — Acute Bright' s disease, diph- 
theria of the respiratory tract, polyarthritic rheumatism, tuberculosis of 
the lungs, pneumonia, traumatism of the nasopharynx (such as an opera- 
tion for adenoids), influenza, the exanthemata, and, in fact, any form of 
inflammation of the nasopharynx may give rise to an acute purulent 
otitis media. 

The acute purulent otitis of typhoid fever is due to the decomposition 
of secretions in the nasopharynx and the entrance of septic matter into 
the drum-cavity by way of thef Eustachian tube, favored by the recum- 
bency of the patient ; not to any specific germ. In influenza otitis, accord- 
ing to Haug,^ the epitympanic space (the attic) is the part chiefly affected. 
Tobeitz ^ has shown that in measles, before the appearance of the exan- 
them, the mucous membrane of the Eustachian tube and middle ear, like 
that of the respiratory and digestive tracts and the conjunctiva, is inde- 
pendently affected ; not by transmission from the catarrhal nasopharynx. 

It does not seem possible to establish any pathologic differences be- 
tween acute catarrhal and acute purulent otitis media, as the same microbes 
cause both conditions, and it is merely a question of resistance on the part 
of the organism, as well as of the wisdom displayed in the treatment of the 
primary symptoms, whether the acute catarrhal otitis media shall become 
a purulent otitis. Every case of acute coryzal inflammation of the Eu- 

^ E. Leutert, Arch, f . Ohrenh. , July and September, 1899. 
' Arch. f. Ohrenh., May, 1896. ^ Ann. f. Kinderheilk., 1887. 

158 



ACUTE PUKULENT OTITIS MEDIA. 



159 



stachian tube and middle ear is potentially an acute purulent otitis media, 
and it depends upon the nature of the treatment of the nasopharynx and 
middle ear whether a purulent process shall be set up. If the treat- 
ment is irritative, — i.e., septic, — purulencj^ of the ear will surely ensue, 
and in many cases with resultant mastoiditis, sinus-phlebitis, thrombosis, 
pysemia, brain- abscess, and meningitis. Xone of these serious and often 
fatal results are necessary sequels of acute otitis media. They are in- 
variably artificial products of improper treatment of the primary inflam- 
mation in the nares and middle ear. 

Acute Tuberculosis of fJie ^IlddJe Ear. — Acute tuberculosis may occur in 
a previously healthy ear. In such a case pus from the ear may contain 
Koch's tubercle bacillus. Pri- 
mary tuberculous disease of the 
middle ear is much more fre- 
quent than is usually supposed 
to be the case, as shown by 
Milligan.^ Tuberculous disease 
of the middle ear is caused by 
the entrance of disease germs 
from the tuberculous nasophar- 
ynx, through the Eustachian 
tube, into the tympanic cavity. 
How ill-advised, therefore, are 
all forms of inflation of the 
drum-cavities in tuberculous 
subjects ! 

On account of the anatom- 
ical relations of the middle ear, 
and the grave results of disease 
of this part of the body, es- 
pecially in children, this organ 
becomes of great imiDortance to 
all practitioners of medicine ; 
yet there is no part of the 
human body so little understood by most physicians. 

The reflex action concerned in the ]3urulent otitis media of teething 
deserves our consideration. ' ' A considerable i3ortion of the blood-supply 
of the membrana tym^jani is derived from an artery that leaves the inter- 
nal carotid in the carotid canal, and proceeds by a very short course 
directly to its destination. Being thus closely connected with a large 
arterial trunk, this small tympanal branch [Fig. 78, 9] of the internal 
carotid artery possesses very favorable circumstances for a speedy aug- 
mentation of its blood-supply. Xow, the nervi vasorum constituting the 




Nervous connection between the teeth and the ear. 
(Woakes.) V , 1, tympanic cavity 2, auricular branch of 
auricula-temporal nerve ; 3, branch from the ganglion 
furnishing vascular nerves to the internal carotid artery 
and its branch the tympanic artery ; 4, otic ganglion ; 
5, branch from otic ganglion joining inferior dental 
nerve; 6, middle meningeal artery ; 7, auriculo-temporal 
nerve ; 8, inferior dental nerve to teeth and gums ; 9, 
short tymiianic branch of internal carotid arterj-. 



1 Brit. Med. Journ., Xovember 16, 1895. 



160 DISEASES OF THE EAR. 

carotid plexus at this part of its course come largely from the otic gan- 
glion [Fig. 78^ 3]. The third branch of the fifth nerve is cut through in 
the diagram to show this ganglion. On the other hand, the inferior dental 
nerve [Fig. 78, 8] supplying the decayed tooth or gums, as the case may 
be, also communicates with this ganglion [Fig. 78, 4, 5]. We thus arrive 
at a direct channel of nerve- communication, through the otic ganglion, 
between the source of irritation, the tooth, and the vascular supply of the 
drum-head. The effect, then, of the irritating impression jjroceeding from 
the decayed tooth or swollen gums will be to excite waves of vessel- dilata- 
tion in the correlated area, the drum-head. Its vessels now become largely 
distended, acute congestion is thus established, with its attendant stretch- 
ing of the sensitive and tense tissue in which it occurs, and so occasions 
the pain experienced by the subject of these conditions. If the irritation 
be sufficiently prolonged, effusion into the tissues ensues, which under 
favorable circumstances will pass into suppuration and constitute a true 
otorrhoea. Owing to the free inosculation of the vessels of the drum- 
head with those su^^plying the tympanic cavity, it will not be long ere 
this region participates in the inflammatory process, so that this cavity 
may also become filled with pus or muco-purulent fluid'' (Woakes). 
Of course this accumulation must either escape by the Eustachian tube, 
as it can in very young children, from the comparatively large size of this 
tube in them, or it ruptures the membrana and runs out at the external 
auditory meatus. Before discharge takes place from the drum-cavity, 
the pent-up matter may press upon the fenestrse and thence upon the 
contents of the inner ear, and excite convulsions. 

Before suppuration ensues in the drum-cavity, inflammation may ex- 
tend from the drum to the meninges of the brain, by the way of the petro- 
squamosal suture, through which a fold of dura mater dips into the tym- 
panic cavity and unites with the muco- periosteal lining of the latter. 
This fissure is wide and the portion of dura mater entering the tympanum 
through it is large in infancy. Towards adult life this fissure becomes 
narrowed or obliterated, but the vascular connection between the drum- 
cavity and the brain continues. 

Symptoms. — In acute purulent otitis media the pain becomes more in- 
tense, the hearing dull, tinnitus louder and distressing, and fever usually 
sets in if it be not already present from other causes. The membrana 
tympani will be found congested and its features lost in the general swelling 
of its surface as the inflammation within the drum-cavity advances. 

Treatment — In this form of otitis, as in the acute catarrhal form, dry 
heat about the ear will be most efficient in allaying the pains, and some- 
times in causing resolution. Warm water or warmed watery solutions 
of carbolic acid (1 to 40) may be tried, but, as has been said, may afford 
little or no relief, though the latter sterilizes the auditory canal and pre- 
pares it for either a spontaneous or artificial perforation of the drum- 
membrane. 



ACUTE PURULENT OTITIS MEDIA. 161 

Inflations, aspirations, etc. , must be carefully avoided now, as in the 
acute catarrhal form, for fear of forcing the pathogenic germs from the mid- 
dle ear into the antrum and mastoid cells. In fact, in this way the large 
number of cases of so-called acute mastoiditis consecutive to acute otitis 
media are caused, — i.e., they are artificial, not necessary results of the oti- 
tis media. In such cases the nasopharynx may be sprayed, not syringed, 
with Dobell's solution, if the nares are filled with tough secretions ; not 
otherwise. Ordinary gentle blowing of the nose will be quite sufScient to 
clear the nostrils. Under the above conservative treatment the earache 
nsually ceases in a few days, either with or without spontaneous rupture. 

If pain continues over six hours in a child, or twelve hours in an 
adult, without spontaneous rupture of the membrana tympani, paracen- 
tesis of the membrane should be performed, because not only hearing, 
but life itself may be at stake in many cases if the drum-membrane is 
not opened in some way. As the inflammation advances the membrana 
tympani will be seen to bulge, especially in its i)Osterior half. Sometimes, 
however, the most prominent portion is in the membrana flaccida. As 
the inflammation in the drum-cavity increases the pain becomes more 
intense, children being thrown into convulsions in some instances, and 
adults made to writhe and scream with pain. After secretion forms in 
the drum- cavity and the membrana bulges, no relief can be obtained until 
the pus escapes by either a spontaneous or an artificial opening in the 
drum-membrane. In time, a spontaneous opening will occur ; but, as the 
tendency is for secretion inside the drum -cavity to inspissate, the longer 
perforation is deferred the less likely it is to occur spontaneously, and 
then the retained secretions will burrow towards the meninges, sinuses, 
and brain-cavity, especially in children. Hence the vital indication is 
prompt paracentesis in a case of acute otitis media with the membrana 
still imperforate after a few hours of great pain followed by bulging of 
any part of the membrane. 

Having sterilized the auditory canal and membrana tympani and 
illuminated these parts by means of the ordinary forehead-mirror, if the 
patient is not etherized, an incision must be made in the most prominent 
part of the membrana. If the patient is etherized, an electric head-lamp 
(Fig. 55) must be employed, as an open flame must not be brought near 
the patient. If daylight can be used, no artificial light is needed. For 
performing paracentesis, or, rather, for incision of the membrana, a knife 
like that shown in Fig. 79 may be employed. Some prefer a knife the 
shaft of which is set at an angle to the handle, like the one in the illus- 
tration, while others prefer, for all operations on the membrana, a straight 
instrument. An incision from one to two millimetres, or even three 
millimetres, long is far preferable to a mere puncture with the so-called 
paracentesis- needle, as such an opening is not sufficient for drainage. Ee- 
covery ensues sooner in cases in which paracentesis has been performed 
than in those in which the perforation is spontaneous. 

11 



162 



DISEASES OF THE EAR. 



In a case of earache with congested and bulging drum- membrane the 
surgeon must be careful to differentiate between simple swelling of the 

outer surface of the membraua as it 
occurs in so-called myringo-derma- 
titis and bulging of the membrana 
from the outward pressure of secre- 
tions on its inner surface. In the 
former the prominence is generally 
more i^unctate and sharply defined, 
often being, in fact, a yellowish, 
.brownish, or livid bulla. In otitis 
media the protrusion from retained 
secretions comprehends more of the 
surface of the membrana, especially 
in its lower and posterior portions. 
In both forms of acute otitis 
media the condition of the mem- 
brana tympani must be watched 
carefully and constantly throughout 
the progress of the disease, because 
only by an intelligent observation 
of its varying conditions can its 
treatment be properly conducted. 

After either spontaneous or ar- 
tificial perforation of the membrana 
there is usually a free discharge of 
muco-pus and a cessation of pain, 
Paracentesis-knife. especially after prompt spontaneous 

opening of the membrane. If this 
has not occurred and paracentesis has been obligatory, the inspissated 
secretions escape more slowly at first and the pain gradually diminishes. 
After any form of perforation of the membrana in acute otitis media 
a discharge must be regarded as beneficial, as it carries off pathogenic 
germs. Therefore little or no local treatment of the ear should be ap- 
plied for fear of secondary irritation of the outer ear and perforation 
of the membrana. If this latter condition is established, the escape of 
secretion from the middle ear is prevented, secondary infection of this 
cavity ensues, and chronicity of the purulency is imminent with mastoid 
complications. Hence the outflow of pus from the acutely inflamed ear 
must be favored. The ear should not be syringed at all at such a time, 
unless the discharge is very thick and not escaping readily. In acute 




cases, for reasons already 



the time to syringe the ear is before 



discharge sets in, and not afterwards, for fear of secondary irritation of 
the perforated membrana and infection of the drum-cavity (page 161). 
In any case of acute purulent discharge, once in twenty-four hours is 



ACUTE PURULENT OTITIS MEDIA. 163 

quite often enough to syringe the ear, if, indeed, it is ever necessary. 
Let the ear run and drain itself through the natural drainage-tube, the 
external auditory canal. Keep the concha and meatus greased with cos- 
moline to prevent chapping, and mop with sterilized cotton or gauze as 
they become filled with secretions, but do not swab them. At the same 
time all forms of inflation, aspiration, and syringing of the nares and 
nasopharynx must be avoided. Under these conservative and rational 
procedures the ear will, in most instances, return to its normal condition 
in the course of two or three weeks. 

I have never seen acute mastoiditis consecutive to acute otitis media 
in a case in which I have treated the primary otitis media from the out- 
set. Therefore I am forced to conclude that when acute mastoiditis fol- 
lows close upon acute otitis media it is purely an artificial result of 
improxDcr treatment, not of neglect of the primary otitis. In fact, total 
neglect is better than improper treatment. Usually the secondary infec- 
tion of the acutely inflamed ear and mastoid is due to the treatment 
applied by the patient, though in some instances by the physician, espe- 
cially if he uses hydrogen dioxide or excessive syringing, or both. 

Of course, the general health and strength must be regarded and im- 
proved in this as in all forms of otitis media. The nares and naso- 
pharynx may demand either moderate si^raying with Dobell's solution 
once or twice in twenty-four hours, or with fluid cosmoline in which a 
few minims of eucalj^i^tol or a grain or two of menthol are suspended. 
Oily as well as watery sprays should be used sparingly, three puffs of the 
atomizer in each nostril being sufficient at an application. 

The local treatment of an inflamed ear, in any stage of any form, 
must be left entirely to the i)hysician. It cannot be carried out by nurses 
or parents with an\^ i3robability of benefit. 

The physician must examine the ear, cleanse it, and then apply the 
treatment indicated by icJiat lie sees in the ear after it is cleaned and in- 
spected by himself. If he can interpret what he sees by inspecting the 
auditory canal and membrana tympani, he will know what to apply or 
whether to abstain from api^lying anything to the drum-membrane. If 
he cannot examine the membrana intelligently, he cannot apply anything 
as a remedy in a scientific way, and should refrain from treating the 
case. In no instance will instillations and powders either prescribed or 
api^lied by a physician in a haphazard way do any good, and syringing 
with anything has done more harm than good to inflamed ears. In acute 
otitis, after discharge sets in after either spontaneous or artificial per- 
foration of the membrana, the less treatment the ear receives the sooner 
it will get well. 

A Case of Acute Otitis Media caused by the NasaJ Douche ; Secondary In- 
fection of the Middle Ear and Mastoid Cavity by Subsequent Improper Treat- 
ment ^ Operation and Relief — The history of the causation of acute otitis 
media, and the evidences of secondary infection of the middle ear and 



164 DISEASES OF THE EAR. 

mastoid process by subsequent treatment, are so accurate and plain in 
this case that I deem it important for the reader to know them. 

Briefly, the history is as follows. April 23, 1896, Eev. J. S., aged 
sixty^ of Ohio, stated that on February 1 of that year he had a slight 
cold in his head, and was advised by a local physician to use the nasal 
douche to obtain relief. He felt at once a stopping up of his left ear, 
but was told to persevere with the nasal douche, though the ear soon 
began to ache, and by February 6 he was suffering with a fully de- 
veloped inflammation of the left middle ear. The ear ached badly for 
a week, during which nothing rational was done for the disease, but the 
nasal douche was continued. Finally, spontaneous rupture of the mem- 
brana occurred and the intense earache ceased. Then his physician began 
a series of moppings, syringings, and instillations in the running ear, 
with counterirritation behind the ear over the mastoid, and the patient 
was directed to inflate his ears by the Yalsalvian metliod. For over one 
month this treatment was kept up, the copious use of hydrogen dioxide 
solution for syringing and instillations comprising a large part of it. 
The ear was not very painful, but the discharge was copious, the mastoid 
grew sore and tender, and pain radiated from this region to the vertex. 

The patient now went to another city to consult an aurist, who con- 
tinued pretty much the same treatment, adding thereto insufflations of 
boric acid. The ear became worse and the general condition of the 
patient bad. He therefore removed to the home of a relative in another 
city, where the local physician continued the above-named infectious 
treatment with the addition of cocaine drops, though the ear continued 
to pour out copious streams of creamy pus, the mastoid pain and soreness 
increased, and the general nervous tone of the patient approached a low 
point. 

Finally, I examined the patient, and found him pale and exhausted 
by pain and loss of sleep. His pulse and temperature, however, were 
normal ; appetite fair and bowels constipated. There was still pain 
radiating from the mastoid to the vertex, which prevented sleep, and 
the mastoid was slightly swollen and a little tender on pressure. The 
membrana was largely perforated in the posterior half, and its outer 
surface, like that of the skin lining the auditory canal, was macerated 
and denuded of epithelium, but there were no granulations in the fundus 
of the canal nor on the membrana. Valsalva's inflation easily forced 
a current of pus from the drum- cavity. 

The patient entered the Presbyterian Hospital, in Philadelphia, where 
all local treatment of the case was stopped, excepting drainage by means 
of a narrow strip of iodoform gauze, and the case observed for two days. 
At the end of this time the only change observed was increase of the mas- 
toid swelling and tenderness. Therefore, on the 25th of April, the patient 
was etherized, and an incision made into the now tumid, red, and tender 
spot behind the auricle. The knife passed down to and through the 



ACUTE PURULENT OTITIS MEDIA. 165 

softened bone, and there was an escape of a little offensive pus. Upon 
farther enlargement of the incision and inspection of the mastoid surface 
a spontaneous perforation, one-fourth of an inch in diameter, was found 
in the cortical surface of the mastoid. This was enlarged so as to admit 
a large curette, and about half a fluidounce of red, jelly-like pulp with 
admixture of pus was spooned out. The mastoid cavity proved to be 
one of the large bullous variety. The walls in all directions were easily 
felt with a probe and the latter was passed into the aditus and attic. 'No 
granulations nor denuded surfaces were felt anywhere. The outline of 
the lateral sinus was easily made out with the probe and curette. Free- 
ing the mastoid cavity of this red pultaceous mass caused considerable 
hemorrhage, but this ceased when the cavity was emptied. Its inner 
surface was then felt to be perfectly smooth. 

A drainage-tube three inches long was inserted, the upper edges of the 
incision were brought together by sutures of silkworm-gut, the wound 
dressed with iodoform gauze, and let alone for twentj'-four hours. It was 
then found that the ear had ceased to run and the mastoid pain had 
stopped. The mastoid wound discharged onlj^ a little bloody serum. 
No pus came from the drainage-tube and the latter was shortened. The 
perforation in the membrane had closed. The wound was now dressed 
with sterilized gauze. On the third day after the operation the drainage- 
tube was entirely withdrawn and the wound dressed with an iodoform 
gauze patch, held in place with collodion. This was renewed every few 
da^'s until June 1, when the mastoid wound had healed. The hearing was 
reduced to one foot for ordinary voice. 

The first error in this case was the use of the nasal douche to relieve 
a cold in the head ; that set u}) the acute otitis media. 

The second error was to allow the ear to ache one week without per- 
forming paracentesis of the membrana tympani. This should have been 
done at the end of the first twenty-four hours of earache, and the ear 
gently stopped with antiseptic gauze, but not syringed nor touched with 
anything for fear of secondary infection. 

The day must come when every man properly qualified to practise 
medicine will know when and how to perform paracentesis of the mem- 
brana tympani, just as he is now supposed to know what to do and how 
to do it in connection with an abscess elsewhere in the body. Until the 
general physician is thus qualified to treat an acutely inflamed middle 
ear, patients will continue to suffer pain, lose their hearing and some- 
times their lives, through the deficiency in those to whom they have 
intrusted their ]3hysical welfare. However, in the case under considera- 
tion spontaneous rujoture was awaited. Even then, had the running ear 
been gently stopped with some iodoform gauze, or carbolized gauze, 
which would have aided drainage of the middle ear, and then let alone, 
secondary infection of the middle ear and mastoid would not have en- 
sued. I regard hydrogen dioxide as one of the worst substances that 



166 DISEASES OF THE EAE. 

can be inserted into the running ear in such cases, as by its expansive 
force it pushes pus into the mastoid cavities and sets up secondary infec- 
tion therein. ^N'othing should he syringed or put in any way into the 
acutely discharging ear. The only time to put anything, and even then 
only a weak, unirritating antiseptic solution of carbolic acid (2.5 per 
cent.), into the acutely inflamed ear is before the discharge begins; for 
such treatment disinfects the auditory canal, frees it from the staphylo- 
coccus albus nearly always present in it, and thus renders less likely the 
invasion of the drum-cavity by this germ when either spontaneous rup- 
ture or paracentesis of the membrana tympani occurs. 

Hence the third and great mistake in the treatment of this case after 
the discharge set in was the month or two of syringings, moppings, in- 
stillations, and insufflations which were directed to the running ear and 
open drum-cavity, and also the Yalsalvian self- inflations of the tympanum 
on the part of the patient by his physician's orders. 

Acute inflammation of the middle ear being caused by the entrance 
of streptococci and other germs into the drum- cavity from the naso- 
pharynx, it is manifest that any form of inflation of the nasopharynx may 
force fresh germs from it into the middle ear, or force pathogenic germs 
already in the drum- cavity into the mastoid cells, which otherwise would 
escape acute infection. 

The acute inflammation thus set up in the ear will generally run a 
self-limited course ending in a spontaneous rupture of the membrane, 
and discharge, which is beneficent, as it carries away the pathogenic 
germs. This current, therefore, should not be impeded in its escape, as 
it will be if secondary infection of the i)erforation and the middle ear 
takes place. 

The staphylococcus albus is the acknowledged cause of secondary in- 
fection and chronicity in aural suppurations, and is generally present in 
the external ear, on the fingers of both patient and physician, and in 
most objects put into the ear. Therefore when the latter is the seat of an 
acute inflammation it is very easy to bring about secondary infection of 
the middle ear and mastoid cavity by anything put into the ear, by either 
the physician or the patient, after discharge sets in. In fact, all chronic 
cases of otorrhoea are thus produced, chiefly, as I believe, by the various 
"domestic remedies" applied by the patient. But the physician is 
sometimes to blame, though unconsciously, because the very substances 
and cotton mops he employs in the ear often contain or x)ush in staphylo- 
cocci, and cause the secondary invasion he is trying to ward ofl*. There- 
fore nothing should be put into the acutely running ear but a strip of 
antiseptic gauze to promote drainage and the outflow of pus. 

Fortunately, with the exception of paracentesis of the membrana 
tympani (not always demanded, however), the best treatment of acute 
otitis media is easy and simple, whereas the improper infectious treatment 
is comparatively difficult and vexatious to both patient and physician. 



ACUTE PURULEXT OTITIS MEDIA. 167 

Mastoiditis icitli Spontaneous Perforation of the Medial Plate of the Pro- 
cess. — In some instances of mastoid empyema spontaneous perforation of 
the medial plate of the process occurs, and pus is poured into the digas- 
tric furrow of the bone beneath the insertion of the sternomastoid muscle. 
The pus thus liberated from the mastoid cells may find its way either for- 
ward along the tract of the digastric muscle, and point in the pharynx, or 
backward towards the nucha, but beneath the deep fascia of the neck in 
both instances. This form of acute mastoiditis, with sx^ontaneous perfora- 
tion of the medial plate of the process, when it takes place occurs in con- 
nection with an acute inflammation of the middle ear, and has been termed 
^'Bezold's mastoiditis,-' because Bezold, of Munich, recentl}^ recalled 
professional attention to it. It was not unknown to the older surgeons. 

Subfascial abscesses in the neck consecutive to acute inflammation in 
the t3'mi)anic and mastoid cavities are said to be not uncommon in 
Europe, Collinet ^ having based his thesis upon two hundred recently re- 
ported cases. Three ways of propagation of the otitic and mastoid sup- 
puration to the neck are recognized, — viz., by way of the veins, by way 
of the lymphatics, and by direct escape of the pus through a spontaneous 
opening in the medial plate of the mastoid i^rocess, beneath the insertion 
of the sternomastoid muscle. By this last-named way pus gets beneath 
the deep fascia of the neck and burrows either backward towards the 
nucha and the dorsal muscles, or forward, via the digastric groove and 
muscle, towards the pharynx, into which it may discharge itself; or it 
may burrow forward and downward in front of the sternomastoid muscle 
until arrested at the clavicle. 

Consecutive abscesses in the neck, propagated thither by venous or 
glandular channels, are, as a rule, more superficial and restricted in their 
area, and hence less serious than the subfascial form. Cases of consecu- 
tive abscesses in the neck, from direct propagation through a spontaneous 
perforation in the medial plate of the acutelj' inflamed mastoid process, 
are the most serious, and therefore attract the most attention from the 
surgeon. After the pus has escaped spontaneously from the mastoid 
cavity to the deep tissues of the neck, the abscess shows no tendency to 
prompt spontaneous evacuation outwardly through the soft tissues of the 
neck, and, if left to itself, burrows farther and deeper inward, producing 
septicaemia and death, especially if the abscess discharges itself into the 
pharynx or lung. 

Symptoms of Spontaneous Perforation of the Medial Plate of the Mastoid 
Process. — After pain has lasted for several days, or even weeks, in a case 
of acute otitis media, the pain in the ear and mastoid may suddenly 
diminish or cease entirely, the otorrhoea continuing nevertheless. The 
mastoid process may or may not have been entirely free from external 
symptoms ; usually, however, it is free from objective symptoms in this 

^ These de Paris, 1897. 



168 DISEASES OF THE FAR. 

form of mastoiditis and remains so. Within twenty-four liours of the 
cessation of pain in the ear and in the mastoid there will be noticed a 
brawny swelling beneath the mastoid process, extending sometimes both 
behind and in front of the insertion of the sternomastoid muscle, but 
generally only behind and below the process, with a tendency to extend 
below and backward towards the region of the splenius muscle. Press- 
ure upon these brawny swellings beneath the mastoid may not be very 
painful, but by such pressure pus can be forced upward and inward 
through the spontaneous opening in the mastoid process, through the 
mastoid cells, antrum, and middle ear, and out into the external auditory 
canal. A patient in this condition usually shows pysemic symptoms, and 
will require an operation for the free escape of pus now burrowing in the 
deep, soft tissues of the neck. 

Treatment. — The mastoid process may have to be laid open and a 
counter-opening made in the neck at the most prominent part of the 
inframastoid tumefaction, whereupon recovery will ensue. In some cases 
only the counter-opening in the retromastoid swelling, withoi^t opening 
the mastoid bone, already spontaneously perforated, will be required, and 
speedy cessation of the aural and nuchal symptoms, with recovery of 
the hearing, will take place, just as occurs after prompt incision into an 
extramastoid suppuration consecutive to spontaneous opening of the 
mastoid cortex behind the ear. 

In some cases of mastoiditis, with spontaneous perforation of the 
medial plate of the process, in which general mastoid symptoms — as pain, 
tenderness, swelling, redness, etc. — demand it, before the counter-opening 
is made in the neck to relieve the gravitation abscess, the outer mastoid 
cortex is to be opened, the cavity exposed, and the passage-way of the 
pus, through the medial plate of the process, and the direction of the 
sinus into the neck are to be sought with a probe, and a counter-opening 
in the neck made accordingly. If the counter- opening in the neck is 
made promptly, — ^.e., as soon as any symptoms of burrowing of pus in 
the neck-tissues show themselves, — quick recovery ensues. But delay in 
operating in such cases is generally followed by septicaemia and some- 
times death. 

The after-treatment of the wound- cavities in an uncomplicated case of 
Bezold's (medial plate) mastoiditis, with burrowing into the neck, is to 
be conducted on general antiseptic surgical principles. 

I have found that in all cases of spontaneous perforation of the mastoid 
after acute empyema, with discharge of pus beneath the soft tissues, 
whether the simple form or the Bezold form of mastoiditis, after free 
incision in the soft parts and escape of pus, especially if fluid syringed 
either through the ear or through the wound escapes at the opposite end 
of the suppurating tract, healing takes place promptly under one daily 
syringing of the tract with a solution of bichloride (1 to 6000) without 
any trephination of the mastoid. 



ACUTE PURULENT OTITIS MEDIA. 169 

A Case of Faucial, J^asal, and Aural Diphtheria. — George Dorsey, three 
years old, vas brought to the Presbyterian Hospital, January IS, 1898, 
with fractured femur and humerus, and with scalp wounds, having been 
struck by a locomotive. The shock was profound, but he reacted well 
and began to recover from his injuries. 

On February 1^ thirteen days after his admission to the hospital, the 
glands of his neck were found to be swollen, and he complained of a sore 
throat, but no patches were found in it. A culture was made from matter 
from his throat, by the Board of Health, giving a positive result. The 
l^atient was then placed in the isolation ward, February 5. At this time 
there was a slight, thin, i)urulent discharge from his nose and ears, but 
no cultures were made from these discharges. At the end of six days, 
all symptoms of foucial diphtheria having disappeared, and cultures from 
faucial matter j)i'Oving negative, though the aural discharge continued, 
the patient was sent back to the Children's Ward, without cultures being- 
made from the nose and ears. He remained well a week, when dis- 
charges began again from his nose, his temi)erature went up, and cultures 
from the nose, by J. D. Steele (bacteriologist of the hospital), Febru- 
aiy 17, were positive as to the presence of the Klebs-Lofiier bacillus, 
streptococci, and stajDhylococci. The child was taken again to the isola- 
tion ward, where he passed through a mild attack of diphtheria, the tem- 
perature never being above 103° F. and the depression slight. 

For two or three days there were exacerbations of tenq^erature. with 
enlarged cervical glands and patches in liis throat, all of which symptoms 
disax^peared under treatment with antitoxin (500 units, Mulford), given 
late in the disease. 

Almost from the first symptom of diphtheria there was a thin, puru- 
lent discharge from the ears, but no cultures were made from it until 
March 12, after the patient's recovery from the second attack of faucial 
diphtheria, when the Klebs-Loffler bacillus was found by culture to be in 
the aural discharge. 

From February 17 to March 2 cultures made by Dr. Steele, fi'om the 
nasal discharge, revealed the presence of diphtheria bacilli, but by March 3 
the cultures from the nose were negative. 

The discharge from both ears continuing, cultures were made from it 
on March 12, those only from the right ear i^roving positive. The same 
result was obtained again on the 13th of March. It was at this time that 
I was asked to see the case and prescribe for it. For the frequent 
syriDgings with hydrogen dioxide I substituted instillations of formalin 
(1 to 1000). These, after a few applications, were followed by disappear- 
ance of the diphtheria bacilli from the ear (negative culture March 16) 
and cessation of the aural discharge a few days later. 

It becomes manifest that even if antitoxin caused disappearance of the 
diphtheria bacilli from the nose and throat, it did not expel them from 
the ear in this case. It is also probable that the second attack of dij^h- 



170 DISEASES OF THE EAR. 

theria of the fauces and nose, February 17, was due to autoreinfection 
(perhaps by the fingers of the child) of the nares and fauces from the 
ears, which still continued to discharge, and, as soon as cultures were made 
from the aural discharge, were shown to contain diphtheria bacilli, 
though cultures from the throat and nose had been shown to be negative. 
It would seem to be only prudent, therefore, in a case of diphtheria, with 
faucial, nasal, and aural discharges, to make cultures from all of these 
localities, and to consider the case still diphtheritic until cultures from 
all of these regions are negative ; otherwise there may be reinfection of 
recovered territories from those still infected, as apparently occurred in 
this case. 

It is also worthy of careful note that the diphtheria bacilli continued 
to appear in the aural discharge until formalin solution (1 to 1000) was 
substituted for the copious syringings with hydrogen dioxide. 

The Ear in Acute and Chronic BrighVs Disease. — There is a distinct and 
undoubted connection between aural disease and nephritis, as shown by 
the observations of J. Morf ^ and many others. 

Affections of the middle ear in Bright' s disease present themselves as 
inflammatory, inflammatory-hemorrhagic, and hemorrhagic. The ear 
may become affected in any stage of nephritis, though otitis generally 
follows an exacerbation of the kidney disease. The subsequent course 
of the aural lesion is directly influenced by that of the nephritis. Some 
French writers maintain that the ear on the side on which the facial 
cedema is most marked becomes aflected. It is also said by Morf ^ that 
both the quantity and the quality of the discharge in chronic purulent 
otitis media are influenced by the oedema. Yoss has declared that '■ ' in 
the late forms of scarlatinous otitis there is one variety that is more 
dependent upon the nephritis than on the scarlet fever itself." The 
connection, indeed, is so intimate that ''the progress of the nephritis 
may be estimated by the course of the otitis." 

In the purulent forms of ear disease in the first group there is a 
marked tendency to caries and necrosis of the surrounding bony walls. 
Inflammatory changes in the Eustachian tube and middle ears are often 
present at the beginning of a nephritis, and hemorrhages into the middle- 
ear cavities are frequent and abundant. I have observed that in such 
hemorrhagic cases epistaxis also exists. 

The aural prognosis depends upon the nephritis ; but the ear disease 
must be regarded as a complication of grave import, especially in the 
purulent forms. Hemorrhages from the ear in nephritis are usually soon 
followed by death. There must be a combination of aural and nephritic 
therapeusis, especially in the first group of nephritic ear affections. 

Mastoid empyema, sinus thrombosis and pyaemia, cerebral and cere- 
bellar abscess, meningismus or pseudomeningeal symptoms in children, 

1 Arch, of Otology, October, 1898. ^ l^^^ ^it. 



ACUTE PUKULENT OTITIS MEDIA. 171 

meningitis and facial i^aralysis, are among the complications of acute 
otitis media. 

Facial Faralysis in Acute Otitis Media. — This symptom occurring in 
acute otitis media may be relieved as soon as paracentesis of the mem- 
brana is performed and blood and pus escape from the ear. Many cases 
of facial paralysis said to be due to '' cold," and treated as neuralgic, are 
in reality caused by acute otitis media, as is shown by the speedy disap- 
pearance of the facial paralysis upon relief of the otitis. 

In some instances a simultaneous inflammation of the facial, acoustic, 
and trigeminus nerves occurs in connection with coryza and otitis media, 
and while the facial and trigeminus nerves may again become normal, the 
deafness sometimes remains permanent. 

Facial paralysis of the so-called rheumatic variety will generally be 
found at least associated with acute otitis media, if not caused by it. In 
the opinion of most observers, every case of facial paralysis from ' ' cold' ' 
is due to a simultaneous acute otitis media. 

Voss^ and others have relieved otitic facial paralysis of several 
months' duration by opening the mastoid and cleaning out the hypersemic 
spongy tissue from the antrum. 

Acute Empyema of the Mastoid. — As has already been said, acute mas- 
toiditis consecutive to acute otitis media in a i^reviously healthy ear is 
usually, perhaps always, the result of improper management of the 
primary otitic affection. 

In every case of purulent otitis media there is, in all probability, an 
attendant emi^yema of the so-called mastoid antrum. It ought to be 
called the tympanic antrum, as it is really a part of the tympanic cavity. 
Sometimes the antrum communicates with the mastoid cells, and hence it 
has received the name of mastoid antrum. When this cavity partici- 
pates in the tympanic inflammation, and becomes filled with secretion 
like the rest of the drum-cavity, it will clear itself as easily as the drum- 
cavity does after an opening occurs in the membraiia tympani. This for- 
tunate result in drainage is assured by a siphonic action which naturally 
sets in as soon as either spontaneous or artificial opening of the drum- 
membrane occurs and the outflowing current of secretion is established, 
as any one familiar with the regional anatomy of these parts must see 
upon reflection. 

Ifj however, secondary infection of the perforation in the membrana 
and of the drum-cavity beyond takes j)lace by an infectious treatment 
through the external ear, secondary infection of the antrum occurs, and 
the patient is then in the first stages of acute mastoiditis. If the an- 
tritis is not speedily relieved, the suppurative process may descend into 
the true mastoid cells, or inward towards the lateral sinus, or forward 
towards the tegmen tympani and thence into the middle cranial fossa. 

^ Arch. f. Ohrenh., November, 1895. 



172 DISEASES OF THE EAR. 

Sometimes all of these unfortunate lesions occur in the same case. My 
experience has been that, if an acute otitis media is treated properly from 
the outset, consecutive mastoiditis will not occur. 

Eegarding the etiology of acute mastoiditis consecutive to acute otitis 
media, I would say that, as I have never seen acute consecutive mastoiditis 
in a case I have treated from the outset of the acute otitis media, I cannot 
regard any case of acute consecutive mastoiditis as a necessary result. It 
seems to me to be due to the artificial secondary infection of the middle 
ear and mastoid cavity from excessive syringing, and especially the use 
of hydrogen dioxide, whereby pus is forced back into the middle ear, the 
aditus and mastoid antrum, and if a communication exist between the 
antrum and the mastoid cells, pus is forced into the latter, and then the 
surgeon is confronted with a mastoiditis of his own creation. In all cases 
of consecutive mastoiditis I have been called to see, hydrogen dioxide 
and excessive lavage had been employed. After either spontaneous or 
artificial perforation of the membrana tympani in an acute otitis media 
the ear should be allowed to drain itself through that most excellent 
natural drainage-tube, the external auditory canal. The more local treat- 
ment the acutely inflamed and running ear receives the more likely it is 
to become macerated, irritated, and blocked, and the discharge impeded. 
Then secondary infection of the ear and mastoid is imminent, and con- 
secutive mastoiditis very likely to occur. After the acutely inflamed ear 
begins to discharge it should be allowed to run, as this running carries 
off pathogenic germs, and is, therefore, beneficial. The ear should be 
mopped dry with slightly singed cotton, the membrana inspected, and 
the extent and position of the perforation determined, if the latter has 
been a spontaneous one. Valuable knowledge may be gained by early 
inspection as to the condition of the auditory canal, especially over the 
region of the antrum. The concha should then be greased with carbo- 
lated cosmoline, and a small ball of sterilized absorbent cotton or gauze 
placed lightly in the concha, and let alone till the drainage tuft is wet ; 
then the latter should be removed and a fresh one put in the concha (not 
in the meatus and canal). Syringing may be needed once in twenty- four 
hours, if at all, and should never be done by any one but an expert, and 
never forcibly. In numerous cases it is not required at all. If the outer 
surface of the membrana require medication, it can be done with a mop 
under illumination with the forehead- mirror. We should not endeavor 
to treat the acutely inflamed middle ear by forcing medicaments through 
the perforation into the cavity. We cannot easily do it, but if we should 
succeed we would do more harm than good. Under cautious, expert 
manipulation, as above outlined, acute otitis media will be well in a week 
or two, and the function of the ear normal. But if any other course is 
pursued, the patient may be under treatment a long time. There are 
many cases in which patients infect their own ears, sometimes by inter- 
ference through the outer ears, and sometimes by Valsalvian autoinflation 



ACrTE PURULENT OTITIS MEDIA. 173 

of the tympana. But in such instances the patient and not the surgeon 
is to blame. 

Sym2)to7ns. — Should the surgeon be confronted with mastoid emi)yema 
in the first or second week of an acute otitis media, he will generally find 
three prominent symptoms, — viz., -pain, prolapse of the upper posterior 
wall of the canal near the membrana, and pyrexia. The pain is usually 
in the mastoid region, or on the same side of the head as the aural inflam- 
mation, and sometimes there is also earache, being either a continuance 
of the original earache or a return of it. There may or may not be ten- 
derness on pressure upon the mastoid. If the latter occurs, it is said to be 
usually near the i^oint of the mastoid process ; but this is not so at first. 
As the acute mastoiditis is ushered in by acute antritis, if there is mastoid 
tenderness on pressure at this time, it is found over the region of the an- 
trum, — i.e., high up and in the front part of the mastoid region close 
behind the auricle. If acute antritis has taken i)lace and an incipient 
mastoiditis is before us, we shall find, in addition to pain in the mas- 
toid, a prolapse or prominence of the skin of the upper j)Osterior wall 
of the auditory canal, near the drum-membrane over the i:)osition of the 
antrum. If these two symptoms are present, the third one of the 
pathognomonic symptoms named above (fever) will also be observed in 
most instances. 

Treatment. — The diagnosis of acute mastoid emi)yema or acute con- 
secutive mastoiditis in a case of acute otitis media being established, 
tlie surgeon must proceed to open the antrum (Fig. 80). Many such 
cases go on to spontaneous rup- 
ture of the outer bony wall of the Fig. 80. 
mastoid and entirely recover, like /-""^^^^ 
any other spontaneously evacu- / fjt*0' 
ated abscess. But, considering the / 
position of a mastoid empyema, 
so near the cranial cavity, it is not 
wise to wait many days for spon- 
taneous opening, because there is h—- 
an almost equal probability that ^~~ 

such an escape of pus from the ^^-^ - ^ ^ 

mastoid may take place on its V:^^^/ 

inner rather than on its outer inner surface of membrana tympani, right side. 

wall. Many cases of mastoid em- «- i^cus ; h, malleus ; c, umbo at lower end of manu- 

, . /I -u f brium ; d, annulus tj-mpanicus ; e, chorda tympani, 

pyema are relieved, by Spontane- passing forward between incus and malleus to 

OUS rupture of the outer cortex, Glaserian fissure ; /, mastoid cells. 

and doubtless many such occur- 
rences are anticipated by a hurried mastoid trephination. But, with the 
three symptoms — pain, prolapse, and pyrexia — manifesting themselves in 
a given case, it is imperative on the surgeon to open the antrum. At 
such a point in the disease the mastoid skin-surface may present no ab- 






174 DISEASES OF THE EAR. 

normal appearance, and the surgeon must operate on the indication of 
the three symptoms or of the pain only. 

An incision down to the bone must be made close behind the inser- 
tion of the auricle, about a quarter of an inch from it, beginning close 
behind the temporal artery and following in a curve the insertion of the 
auricle to the mastoid tip below. The auricle must now be drawn 
forcibly forward and the region of the antrum sought (Fig. 11, p). If in 
this search a spontaneous opening in the bone has occurred, this opening 
may be enlarged with chisel and hammer by the surgeon, and the antrum 
sought and cleaned out. If there is no spontaneous opening in the bone, 
the surgeon must open it over the antrum with chisel and hammer, and 
work his way cautiously upward and forward. 

In the adult's bone this opening should be of a funnel-shape, with its 
mouth directed outward. It should be about ten millimetres deep and 
from one to one and one-half centimetres wide. If the bone is not hy- 
perostotic, as it rarely is in acute cases, such an opening as the above 
will generally expose the antrum. Great care must be exercised not to 
wound the facial canal as the surgeon approaches the aditus. In acute 
cases it is rarely necessary to enter as far as the aditus. 

After a mastoid operation in acute cases Blake allows the wound 
cavity to fill with blood, thus hastening healing by first intention. The 
same method may be tried in chronic cases, excepting when in the chronic 
case the extent of the field of operation makes it necessary to resort to 
packing of the wound for other reasons. 

The wound should not be irrigated, but simply lightly tamponed with 
iodoform gauze, if there is no parenchymatous hemorrhage ; if the latter 
occur, the wound may be packed more firmly with iodoform gauze. 
Dressings should be changed in from one and a half to three days, accord- 
ing to the degree of moisture. At such a time any moisture in the wound 
should be mopped away with strips of sterilized gauze, and the auditory 
canal left open from the outset. As iodoform gauze hinders granula- 
tion, the later dressings should be simple sterilized gauze. Eetention of 
pus may ensue in a mastoid wound if healing on the outer side is allowed 
before healing from the bottom takes place ; yet long- continued tampon- 
ing delays healing. 

Cerebellar abscess may result from acute purulent otitis media, espe- 
cially if spontaneous rupture of the membrana does not occur promptly 
in a few hours, and paracentesis is delayed, as shown in a case reported 
by the author. ^ 

1 Amer. Med. Assoc, Detroit, June 9, 1892. 



CHAPTEE XTII. 

CHEOXIC PrEULE^'T OTITIS MEDLi. 

Chronic Purulent Otitis Media. — This affection is due to the permanent 
lodgement of staphylococci in the acutely inflamed middle ear, and is 
usually caused by improper treatment of the acute otitis media, generally 
by the patient, but sometimes, it must be admitted, by the physician. 

Sym2:>toms. — The chief symj^toms of uncom]3licated chronic purulent 
otitis media are either hardness of hearing or profound deafness and a 
purulent discharge from the ear. There may also be tinnitus aurium, 
more or less constant, and occasional attacks of vertigo. In the debili- 
tated and squalid there maj' be frequent attacks of earache and so-called 
*' gatherings in the ear.'' The vibrating tuning-fork placed on the vertex 
may be heard quite well in the diseased ear if the labyrinth has not been 
invaded by the inflammation. Should the x)atient fail to hear the tuning- 
fork, by bone conduction, in the diseased ear, it would indicate that prob- 
ably the chronic purulencj' had invaded the inner ear, and that the case 
all the more demanded i:>romi)t treatment to i^revent still deeper advance 
of the disease. 

The Discharge. — The discharge is usually more copious in children 
than in adults. In the latter the discharge is more likely to be copious 
the less chronic the disease. As the disease advances, the mucous mem- 
brane is either destroyed or so gi*eatly altered in structure as to cease 
to throw off much secretion, and in such cases the discharge becomes 
thinner, more offensive, irritating, and suggestive of necrosed bone. In 
children the discharge is copious because of the usuallj' attendant ac- 
tivity of the mucous membrane of the nares, nasopharynx. Eustachian 
tube, and middle ear. Hence in young patients the purulent discharge 
is mixed with strings of mucus, more or less transparent, from the Eu- 
stachian tube and tympanic cavity. The color of the discharge varies 
from a light yellow to a dark yellow or green, but there is no rule about 
this feature. It will be observed that the more copious discharges from 
the ears of young children are lighter in color than the scanty, which 
are usually quite dark. The slighter discharges of adults afilicted with 
chronic purulency in the middle ear are dark and more likely to form 
crusts in the meatus. 

In most cases there seems to be a peculiar butyric odor to the dis- 
charges of chronic suppuration from the ear. This is largely due to a 
want of cleanliness. There will be very little odor in an ear thus dis- 
eased if it is kept clean and no necrotic bone is retained. 

175 



176 DISEASES OF THE EAR. 

Minute perforations in the membrana are attended by slight and inter- 
mittent discharge. The chronic purulent inflammation in such cases is 
limited to the inner surface of the membrana tympani, near the per- 
foration. 

Appearances of the External Auditory (7a?iaZ.— Inspection of the ear by 
means of the ear-mirror and the ear-funnel or speculum will reveal muco- 
pus in and about the meatus and lying in the canal, more or less macera- 
tion of the skin of the auditory canal, and perforation or entire destruction 
of the membrana tympani, with inflammation of the mucous membrane 
beyond it in the drum-cavity. In order to obtain a good view of the 
external auditory canal and drum-head, the canal must be mopped dry 
with absorbent cotton on a cotton-holder, or syringed, and then it and 
the fundus of the canal and membrana gently mopped dry by means of a 
tuft of absorbent cotton on a cotton-holder. Syringing alone or mopping 
alone is rarely able to cleanse the ear sufficiently to allow of a good view 
of the diseased parts at the first examination. Inspection of the dis- 
eased ear after cleansing will reveal maceration of the cutaneous lining 
of the canal, and in very chronic cases one or more small exostoses, 
generally in the fundus of the passage near the annulus tympanicus. If 
the chronic discharge is not copious, the maceration of the skin in the 
auditory canal is not great. Instead of that, there are formed scales and 
crusts of hardened pus, mucus, and epidermis in the inner part of the 
auditory canal and on the outer surface of the upper part of the drum- 
membrane in the region of the membrana flaccida. In cases of copious 
discharge, the delicate skin lining the inner part of the bony auditory 
canal becomes more like mucous membrane than like skin, as it is de- 
nuded of epithelium and secretes a thin pus. This has led to the erro- 
neous idea that the inner part of the auditory canal is normally lined 
with mucous membrane. This condition of the skin in the auditory 
canal is oftenest seen in those who have resorted to swabs of various 
sorts for cleaning their ears. 

Appearances of the DrumSead and the Tympanic Cavity. — Chronic puru- 
lent discharge from the tympanic cavity presupposes a perforation in the 
membrana tympani. Such a perforation may be at any point in the 
membrana, least frequently, however, in the flaccid part, the so-called 
Shrapnell's membrane. Let us first consider disease of the atrium or 
lower part of the drum-cavity, with perforation of the membrana tensa, 
the part below the folds of the drum-head (Fig. 81, 5, 5). Generally in 
such cases the attic is little involved and the membrana flaccida imper- 
forate. A perforation in the membrana tympani may vary from the size 
of a pin-hole to that which embraces the entire drum-head. Usually, 
even in the worst cases, a rim about the annulus tympanicus is left, from 
which, if the purulency is stopped, a new membrana may grow. The 
usual seat of a perforation is in the posterior half of the membrane. 
Multiple perforations are rare; sometimes, however, two may be found 



CHRO^'IC PURULENT OTITIS MEDIA. 



177 



Nevertheless, a large 



Fig. 81, 



12 1 



close together in the under i)art of the membrane, separated by a thin 
band, and in very rare cases three perforations may be found in the same 
membrane. The handle of the malleus may remain intact^ notwithstand- 
ing great destruction in the drum-head. In other instances the manu- 
brium may be more or less eroded as the perforation extends. If the 
membrana is destroyed, or if the perforation in it is in the upi)er and 
hinder part, the lower portion of the long process of the incus, the incudo- 
stapedial joint, and the rami of the stapes, as well as the niche for the 
round window, may come into view after the ear is cleansed from pus 
and then dried out with cotton on a cotton-holder, 
perforation may exist in the uj^per 
and hinder parts of the membrana 
tympani, and the incus and stapes 
be intact, yet invisible, becanse the 
mucous membrane about them is 
too swollen to permit of their ready 
recognition. When a large perfo- 
ration is in the upper posterior 
quadrant, the lower ends of these 
ossicula may be seen by inclining 
the patient's head towards the op- 
posite shoulder, and then looking 
up and behind the rim of mem- 
brana still inter A^ening between 
them and the observer. This view 
will be favored by the observer's 
slowly moving his head and eye so 
as to command all parts in the 
region of the roof of the tympanam. 
There is a form of chronic sup- 
puration of the middle ear origi- 
nating in and usually limited to the 
attic space {recessus ejntijmpanicus), 
or ux^ijer part of the drum-cavity 

beneath the tegmen tympani (Fig. 22, 1). These are the so-called "attic 
cases." Thej^ are characterized by a perforation in the membrana flaccida 
or Shrapnell's membrane (Fig. 81, 1, 1), an imperforate membrana tensa, 
the part below the folds of the drum-head, and a scanty, offensive dis- 
charge, clinging chiefly to the upper wall of the auditory canal. So slight 
is this discharge in most cases of attic suppuration that the membrana 
tensa is generally entirely dry, and when the ear is fii^st inspected it 
appears to be free from secretion. Ui)on close examination, however, of 
the upper wall of the auditory canal and the upper part of the membrana, 
above the line of the folds and short process, a film of pus will be seen. 
AYlien this is mopped away the perforation in the membrana flaccida will 

12 




Outer surface of a normal membrana tympani, 
left side ; magnified three and a half diameters. 
(Politzer.) 1,1, membrana flaccida (Shrapnell's 
membrane) ; 2, short process of the malleus ; 3, 
posterior fold of the membrana tympani ; 1, incus- 
stapes joint showing through the membrana ; 5, 5, 
membrana tensa, behind which lies the atrium ; 
f). 6, 6, 0, inner end of the bony auditory canal, 
forming a frame for tlie membrana tympani ; 7, 
pyramid of light ; 8, umbo, containing the lower 
end of the haiidle of the malleus ; 9, anterior fold 
of the membrana. 



178 DISEASES OF THE EAR. 

be made apparent. This perforation may be very small, and a small gran- 
ulation or polyp may lie over it or protrude through, it. If the perforation 
is large, the neck of the malleus may be seen through it, or if a portion 
of the margo tympanicus — the osseous edge of the squama forming the 
part of the tympanic ring at the Eivinian segment — has been destroyed 
by caries, the entire head of the malleus and part of the body of the incus 
connected with the malleus may be visible. Sometimes, though this per- 
foration is very large, disease having destroyed the head of the malleus 
and the incus, the perforation reveals an empty antro-tympanic space. 

Memhrana Flaccida. — The membrana flaccida may be briefly described 
as a fan-shaped region, the lower borders of which, or the imagined 
sticks of the fan, run backward and forward from the short process of the 
malleus above the upper edge of each so-called fold of the membrana tym- 
pani, forming a lower boundary about five millimetres long (Fig. 81, 1, 1)» 
The upper edge of this important part of the membrana tympani corre- 
sponds to that peculiar part of the general perii)hery of the drum-head 
known as the segment of Eivinus. The latter is more accurately described 
as the margo tympanicus (the scute) or inner edge of the upper bony wall 
of the external auditory canal, and forms the osseous complement at 
this point of the annulus tympanicus. The membrana flaccida thus out- 
lined is about three millimetres high, measuring from the short process of 
the hammer up to the point of attachment of the membrane to the uj^per 
osseous wall of the auditory canal. This membrane is composed of only 
two layers, an outer cutaneous one from the auditory canal and an inner 
mucous layer from the tympanic cavity and inner surface of the margo 
tympanicus. Directly behind the central part of the membrana flaccida 
is the neck of the malleus, the head of which lies behind the margo tym- 
panicus (Fig. 30, 2). The front part of this membrane is stretched over 
the anterior upper part of the tympanic cavitj^, entrance to which, at 
this point, is above the so-called anterior pocket of the drum-head. The 
back part of this flaccid membrane, behind the neck of the malleus, is 
stretched over the front end of a long and shallow groove yet to be 
described, and at this point the membrana flaccida is about two milli- 
metres from the lower part of the body of the incus. This posterior 
groove-like cavity is wedge-shaped, bounded on its inner side by the 
upper part of the body of the incus and its short horizontal process, and 
on its outer side by the inner surface of the margo tympanicus. The 
edge of the wedge-shaped groove points downward and its base opens 
upward towards the tegmen, while in its long diameter it widens and 
forces a way backward into the tympanic cavity and the mastoid antrum. 
At its anterior end and on its outer side this groove is covered in from 
the external auditory canal by the back part of the membrana flaccida. 
Hence when this membrane gives way at this point, egress is afforded to 
matter from the upper and back part of the tympanic cavity and from 
the mastoid antrum (Fig. 22). 



CHRONIC PURULENT OTITIS MEDIA. 179 

Various Fositions of the Perforation. — Sometimes a perforation in the 
membrana flaccida is directly above the short process of the malleus, 
opening into what is termed by Prussak and Brunner a ^^ third pouch of 
the membrana tympani." In perforations of the central jxirt of the mem- 
brana flaccida the neck of the malleus is exposed. In anterior j)erfora- 
tions of this membrane, entrance is effected directly into the large upper 
space in the front part of the tympanic cavity, near the tympanic end of 
the Eustachian tube. 

Posterior perforations are usually attended by great discharge and mas- 
toid symptoms 5 they are also most obstinate and accompanied by pro- 
found deafness. Central perforations are most likely to be connected 
with disease in the external auditory canal, but are less obstinate to treat- 
ment and are not usually associated with profound deafness nor so great 
a discharge. 

Anterior perforations are most likely to be connected with disease in the 
nares, the Eustachian tube, and the tympanic cavity, and they give exit 
generally to a more copious discharge than any other form of attic disease. 

In cases of destruction of the entire membrana flaccida, attended by 
erosion of the margo tympanicus, there come into view, directly over the 
line of the folds of the drum-head, the neck and head of the malleus and 
the junction of the latter with the incus, the body of the incus with 
the upper part of its descending crus, and the proximal part of its short 
horizontal crus. In such cases of extensive destruction the entire dome 
of the tympanum under the roof can be viewed by turning the patient's 
head to the opposite side. There may also be seen the cavity of the 
upper and front part of the tympanum, and a dark cavity in the back 
part of the space thus oj^ened around the head of the malleus and body 
of the incus, which is the entrance to the mastoid antrum. 

When the perforation is in the anterior part of the membrana flaccida, 
Valsalvian or other inflation is likely to produce a characteristic perfora- 
tion-whistle ; but when the perforation is elsewhere in the flaccid mem- 
brane, a perforation-whistle is not likely to be produced. This can read- 
ily be understood upon reflecting that, except in anterior perforations, 
the head and neck of the malleus and the body of the incus intervene 
between the cavity of the tympanum and the perforation. Another 
peculiarity of these cases in which a wide perforation is in the mem- 
brana flaccida is the absence of perforation in the membrana tensa below 
the folds. Even when disease in the atrium exists, with purulency in 
the attic, the perforation in the membrana flaccida is often the only out- 
let. Doubtless there are cases in which purulency in the antrum, with a 
perforation in the membrana tensa, is associated with purulency in the 
attic and a perforation in the flaccid membrane, but the more complete 
drainage of the drum-cavity offered by the lower perforation renders it 
very unlikely that the perforation in the flaccid membrane will be large 
or even continue to exist. 




180 DISEASES OF THE EAR. 

The deafness in cases of attic purulency is explained by the nearness of 
tlie suppuration to the ossicles of hearing and their impaired motility thus 
"brought about. Patients with attic suppuration are more apt to suffer from 
dizziness than those with purulency in the atrium, because in the former 
instance the suppuration is more likely to irritate the stapes in the oval 
window, and thence the labyrinth through the tissues of the vestibule. 

Perforation in the membrana flaccida always means necrosis in the 
malleus and perhaps in other of the ossicula auditus. It is fortunate if 

this is not attended by necrosis 
in the margo tympanicus and 
other parts of the surrounding 
attic walls. 

Treatment. — There are four 
methods of treating chronic puru- 
lent inflammation of the drum- 
cavity, — viz, : 1. By injection of 
fluids through the perforation in 
the membrana by means of a tym- 
I)anic syringing or by inserting 
them on slender mops through the 
perforation, and squeezing out the 
medicament by firm pressure. I prefer the latter. If a tympanic 
syringe is desired, one like that shown in Fig. 82 will be found u.seful ; 
bub no one but an expert can use it. 2. By the introduction of powders 
or solids through the perforation, if it is large enough. 3. By excision 
of the membrana tympani, including the remnants of the membrana 
flaccida, the malleus, and the incus. 4. If all of these methods fail to 
cure chronic purulency of the middle ear, the surgeon should resort to a 
surgical exposure of the middle-ear cavities, the drum-space, the aditus 
and antrum, and the removal of all diseased tissue in them. The 
methods of accomplishing this will be described later on. 

Antisepsis can be best obtained by syringing the ear by the way of the 
auditory canal or by mopping it with absorbent cotton. Cleansing the 
ear, as about to be described, should be done only by the surgeon. For 
syringing the ear, a solution of common table-salt in warm water (five 
per cent.), a solution of carbolic acid (two and a half per cent.), a solu- 
tion of bichloride of mercury (1 to 3000 or 1 to 4000), and a weak solution 
of potassium permanganate are among the simplest and best. If the 
secretion is very thick and tenacious, a solution of hydrogen dioxide may 
be instilled slowly into the ear. This valuable drug cannot be heated 
without decomposing it, and therefore has to be used at the temperature 
of the surrounding atmosphere. It thus constitutes an exception to the 
rule to use warm solutions for instillation or syringing into the ear. This 
solution breaks up thick pus, and then the ear may be further syringed 
and thoroughly cleansed with an antiseptic fluid. 



CHRONIC PURULENT OTITIS MEDIA. 181 

It should not be necessary to saj^ that the injected fluid must be kei)t 
separate from the return fluid which comes from the ear loaded with 
the iDroducts of suppuration. This can be done by using a vessel with a 
partition across the diameter, or by having two basins, one full of the 
fluid to be injected and the other empty for receiving the washings from 
the ear. 

If the quantity of discharge is both slight and thin, it can be moi^ped 
out of the external auditory canal and its fundus by absorbent cotton on 
a cotton -holder, under thorough illumination of the ear by the forehead- 
mirror (Fig. 57) or the forehead electric lamp (Fig. 55). 

While this method will grossly cleanse the ear, so that a view of the 
fundus of the canal and the membrana tympani may be obtained, it will 
not chemically cleanse it and render it aseptic. Therefore, if a more 
thorough antisepsis is to be sought by means of the mo^) on the holder, 
the cotton mop must be soaked with some antiseptic, and the fundus 
of the canal and the tympanic cavity, as far as possible, gently but thor- 
oughly mopped and washed with the excess of the antiseptic fluid which 
will be then squeezed out into the diseased region, under good illumina- 
tion, as just stated. There must be no perfunctory mopping in the ear 
in any case, nor any guesswork about these manii:)ulations. Therefore 
they can be done only by the skilful and conscientious surgeon. 

After the ear is cleansed it should be thoroughly and most carefully 
examined first for granulations and polypi. If such complications are 
detected, they must receive treatment as hereinafter described. 

If these obstructions to treatment and vision do not exist, a slender 
but blunt probe should be passed carefully down the canal, and the walls 
of the osseous canal, the malleus or its remnant, and the inner wall of the 
tymi^anic cavity should be cautiously examined for denuded, carious, or 
necrotic spots. It is very important to know whether the latter condi- 
tions exist in the ear about to be treated, as their presence contraindicates 
all forms of caustic treatment, especially in caries of the inner tympanic 
wall. The facial canal, which at best is separated from the tympanic 
cavity only by a thin osseous wall, and which often, even in a healthy 
ear, has a dehiscence in it from defective ossification, is easily j)enetrated 
by any fluid put into the drum-cavity, and the facial nerve directly at- 
tacked. If caries of the inner wall of the drum-cavity exists, the thin 
facial canal-wall is almost surely open and the facial nerve exposed. It 
is not uncommon to see an acute attack of otitis media from a cold in the 
chronically diseased ear followed by facial palsy, simply from pressure 
upon the nerve by the swollen mucous membrane of the drum- cavity. 
What may not follow the application of a caustic to the carious tympanic 
wall if the facial canal is oi^en ? In fact, lasting facial paralysis has thus 
been caused. The treatment of caries of the canal, the malleus, and 
other ossicula of the tympanic cavity and adjacent i^arts will be con- 
sidered farther on. Whether or not caries and necrosis exist, in chronic 



182 DISEASES OF THE EAE. 

suppuration of tlie middle ear caustics will never render the safer aid 
obtainable from mild antiseptics. 

Asepsis having been obtained as stated above, an endeavor must be 
made to maintain it. The ear should be cleansed every day or two, ac- 
cording to the nature and quantity of secretion and the rapidity of its 
formation. Some cases secrete a thin muco-purulent matter^ while others 
tend to the formation of thick pus. Any discharging ear is offensive in 
odor if it is not kept clean, and even those which are the most offensive 
when first seen soon emit very much less odor when they have been kept 
clean for a few days. After syringing with a simple antiseptic wash, the 
ear may be mopped out with an aqueous solution of formalin (1 to 1000), 
carbolic acid (1 to 40), mercuric bichloride (1 to 5000), or with spirit of 
wine. Some authorities convey antiseptic solutions directly to the drum- 
cavity, through the perforation in the drum-head, by means of the tym- 
panic syringe (Fig. 82). 

After the ear has been cleansed it may be rendered more continu- 
ously aseptic by the insufflation of finely powdered borax, boric acid 
calendulated, ^ boric acid and iodoform (seven parts of the former to one 
part of the latter), resorcin, aristol, europhen, nosophen, or boric acid 
hydrastinated in the same manner as boric acid is treated with tincture 
of calendula. 

These are more or less soluble, simple, and efficient, but must be blown 
in in small quantities, just enough to dust over the fundus, and never 
packed in or held in by a tampon. Asepsis and the checking of the dis- 
charge must be the aurist's aim, not the retention of matter. Therefore 
no application should prevent the escape of ]3us from the ear, as all forms 
of sticky ointments, oils, or tampons will surely do. Powders may be 
insufflated into the ear by means of hand powder-blowers, or by a blow- 
pipe made of a foot of soft -rubber tubing and a quill or glass end-piece 
for taking up the powder and conveying it into the ear-funnel, — of course 
under perfect illumination (Fig. 57). A better aim at the diseased parts 
can thus be taken, and a gentle puff from the surgeon's mouth will carry 
the powder directly to the fundus, to the attic or the atrium, or to any 
spot on the walls of the auditory canal. Some authorities convey fine 
powders, like the above-named, directly to the drum-cavity by means of 
a powder-blower with a very long and fine nozzle resembling that of the 
tympanic syringe. 

Treatment by antiseptic powders or instillations should be carried out 
daily for a few days, and then every second day, or at longer intervals, 
as the discharge begins to decrease. If this treatment by antisepsis and 
asepsis does not benefit the patient within a month or two, if the mucous 

^ Take equal parts of boric acid and tincture of calendula, minim for grain, and 
let them dry over a water-bath. Then retriturate the dry powder and mix with pure 
boric acid, one part of the former to two parts of the latter (S. Sexton). 



CHRONIC PURULENT OTITIS MEDIA. 183 

membrane of the drum-cavity is granulating or swollen and drainage from 
it defective, and if the malleus or any portion of the tympanic wall is 
carious, the membrana tympani, the malleus, and the incus should be 
excised. 

Granulations. — A jDurulent inflammation of the middle ear may lead 
rapidly to the formation of granulations (small polypoid growths) about 
the edges of the perforation and on the mucous membrane of the drum- 
cavity. These results are most likely to occur as a consequence of neg- 
lected and chronic suppuration of the tympanum. Granulations are 
rarely attached to the skin of the auditory canal unless the skin has been 
ulcerated or wounded during the i)urulent i^rocess in the tympanic cavity. 
All granulations should be considered incipient i)olypi. True polyj)! are 
insensible to the touch. 

Folypoid hypertrophy of the mucous membrane of the middle ear, with 
hernial protrusions through the perforation, occurs not uncommonly in 
chronic sui^puration of the drum-cavity. These i)rotrusions resemble 
polypi in aj^pearance, but, unlike them, are very sensitive to the touch. 
The mucous membrane of the tympanic cavity is in any case predisposed 
to hyperplastic processes and to the formation of rugous elevations and 
firm projections. By continued growth and constant enlargement these 
formations may entirely fill u^) the tympanum, and, after i^erforation of 
the membrana tympani, fill the entire auditory canal. They may also 
cause flat, bridge-like adhesions to form between the membrana tympani, 
the auditory ossicles, aud the walls of the tympanic cavity. Cystic 
ca\'ities may be formed by the union of several elevations with one 
another. 

Aural Polypi. — Aural polypi vary in size from one millimetre to three 
or four centimetres in length. The latter, after blocking the entire audi- 
tory canal, extend beyond the meatus into the concha. Their surface is 
usually papillated, looking like a mulberry, particularh^ near their base. 
Their consistence is soft but elastic, and their color may be any shade of 
grayish pink or red. Aural polypi are often multiple, several being 
found in the same ear. In very rare instances one of the auditory ossicles 
may be embedded within the substance of the polyp. A polyp, by its 
pressure, may markedly enlarge the osseous part of the external auditory 
canal. Polypi may originate from the mucous membrane or muco-peri- 
osteal lining of any portion of the tympanic cavity. In some instances 
they may spring from the dermoid layer of the membrana tympani or 
from the skin of the external auditory canal. Their most frequent point 
of origin is from the upper and inner walls of the drum-cavity. 

Polypi are most frequently found in males, and before thirty years of 
age. The vast majority occur in cases of suppurative disease of the 
middle ear, and when they are situated on the wall of the external audi- 
tory canal it will be found that the suppurative process has been a ^vo- 
longed one. In fact, all these growths may be considered inflammation- 



184 DISEASES OF THE EAR. 

tumors, distinctly illustrating the doctrine of the inflammatory origin of 
all neoplasms. 

Aural polypi should be classified as follows : 1. Granulation-tumors. 2. 
Soft papillomata. 3. Fibromata. 4. Myxomata. 

It cannot be said that there is any special train of symptoms indica- 
tive of the presence of an ordinary aural polypus. Wherever a chronic 
purulent discharge from the ear has existed for some time, the presence 
of a polypus may be suspected, especially if from time to time there has 
been any hemorrhage from the ear. Usually, however, the only symptom 
is the chronic discharge from the ear. 

Reflex Fhenomena. — In some rare instances aural polypi may produce 
hemiplegia, anaesthesia, and ptosis without facial paralysis on the corre- 
sponding side. Eemoval of the polypi usually causes the symptoms to 
vanish. Other reflex phenomena from the peripheral irritation arising 
from a polypus in the ear have been observed, such as epileptiform con- 
vulsions, severe occipital pain and i^ain in the ear, unsteadiness of gait, 
elevation of temperature, complete paralysis of the facial nerVe,^ a con- 
stant tendency to faintness, and great muscular weakness, all of which 
have disappeared upon the removal of the polypus from the ear. 

Hemicrania, sensations of fulness in the ear, vertigo, retention of 
pus, nausea, and vomiting have often been observed as a result of the 
presence of a large obstructive polypus in the auditory canal ; but they 
are not to be regarded as characteristic of the presence of polypi gen- 
erally. The vast majority of aural polypi are first discovered by the 
surgeon when the patient applies for relief from a chronic aural discharge, 
the latter being the only symptom. 

Treatment of Granulations and Folypi. — Granulations usually disappear 
under careful antisepsis of the ear, especially when it is maintained by 
powders or by instillation of alcohol. If this simple form of treatment 
does not check the discharge and cause the granulations to disappear, the 
latter may be most carefully touched with chromic acid. This should 
be done by dipping a probe, with an end not more than one millimetre 
in diameter, into a drop of deliquesced chromic acid crystals, and then 
touching, under perfect illumination, each granulation with the point 
of the probe thus wet with the escharotic. Is'othing but the granulation 
should be touched by this powerful acid. The part touched instantly 
turns yellowish white, and the discharge from the ear is usually a little 
increased for a day or two, owing to the sloughing induced by the caus- 
tic. This acid should never be applied to the ear except under the 
most perfect illumination from the forehead- mirror or the forehead elec- 
tric lamp, and by a skilled hand. Any other course will surely pro- 
duce a slough in healthy tissue and the ear will be made worse. Fortu- 
nately, the antiseptic powder already named will usually cause granulations 

^ R. W. Seiss, University Medical Magazine, Philadelphia, July, 1889. 



CHRONIC PURULENT OTITIS MEDIA. 185 

to disappear without resort to chromic acid. Let it be distinctly under- 
stood that the latter should never be api)lied to the ear on cotton on the 
cotton-holder or in any other way, as too much acid will be taken up by 
the cotton, and, when pressed uj^on the granulation, more than is required 
will be pressed out and will run over adjacent tissues. 

Folypoid hypertropluj of the mucous membrane of the middle ear, with 
hernial protrusion through the perforation, is often mistaken for a polypus 
and treated as such by caustics. Unlike a x^olypus, such protrusions of 
mucous membrane are very sensitive to the touch, while true pedicellate 
polypi are not. This will serve in establishing a differential diagnosis 
and greatly modifying the treatment. A protrusion of the mucous mem- 
brane should never be cauterized nor snared off, as it will disappear 
under insufflations of antiseptic i^owders. This I have verified repeatedly. 
Cauteriziug or snaring them is not only painful, but is very likely to set 
up an acute otitis media. 

A iruQ pedicellate polypus in the ear is not difficult of diagnosis. After 
the ear has been cleansed, inspection of the auditory canal and fundus 
reveals a more or less bright red and shining body either in the fundus, 
near or upon the membrana tympani, or farther outward in the canal, 
nearer the meatus, the lumen of which is often filled by the growth by 
the time it has extended so far outward, A more or less copious and 
offensive discharge from the ear exists at the same time, and usually it is 
for the latter that the surgeon's aid is asked. 

The first step in the case must be the removal of the polypus, in order 
to free the ear from the irritation of its presence, to i)erfect drainage of 
pus from the middle ear, and to apply medication. Patients must be told 
that the removal of the j)olyi:>us is only the first step in treatment, as its 
pedicle or ''root" must be thoroughly destroyed in order to prevent re- 
growth. If the pedicle is properly treated, regrowth never occurs, 
though an entirely new polypus might form if the dischai-ge were not 
checked, or if the ear were entirely neglected as to daily cleansing. 

A little cocaine (a five or ten per cent, solution) may be droi^ped into 
the ear in order to blunt the sensibility of the walls of the auditory canal 
and fundus ; the polyp itself is insensitive. However, this is not de- 
manded if the oi^erator has skill and his instrument is slender. Further- 
more, cocaine does not act readily on the skin-tissue of the external ear. 
Patients, however, are often reassured by dropping a solution of cocaine 
in the ear before a x)olypus is to be extracted. 

Polypus Snare. — The owlj good surgical means of removing an aural 
polypus is the so-called polypus snare. This should consist of a slender 
canula, six centimetres long and one millimetre in diameter, as modified 
by the author from the "VVilde and Blake instruments. The former is 
entirely rejected at the present day on account of its clumsiness and size. 
In its original condition it was too large to be convenient, because the 
width of the shaft and the exposed wires was nearly as great as the canal 



186 DISEASES OF THE EAR. 

diameter itsell^, and hence darkened tlie canal and filled it up so that the 
distal end of the instrument could not be seen, in most cases, after it had 
passed beyond the meatus. 

C. J. Blake confined these wires forming the -snare in a canula that 
flared slightly at the end, and thus at once provided the aurist with a 
compact polypus snare. Subsequently, C. H. Burnett narrowed the 
canula still further and did away with the flare at the loop end, which 
gave a better view of the fundus and the body about to be seized by the 
snare (Fig. 83). Across the mouth of the canula is placed a little bar, 
which prevents the loop from being drawn into the barrel. Various, 
kinds of wires and threads have been employed to run in the canula and 
form the loop. In the writer's experience no form of wire acts so well in 
this instrument as the brass wire used in harness-making. It is bright, 
fine, and flexible without being too flimsy to maintain a loop, and is 
quite strong enough to constrict an aural polypus pedicle. Iron and 
silver wire are too stifl", and hence make loops at once unmanageable 
and harsh. 

Polypus Sooh. — Sometimes small polypi may be caught and removed 
on a hook made for that purpose. But hooks are treacherous objects in 
the ear, as in so narrow a place they are likely to catch hold of the walls 
of the canal and inflict painful wounds, which are avoided by using the 
slender forms of polypus snares. Therefore, if a hook is employed for 
the removal of a polypus, it must be very slender and small (Fig. 84) 
and used only by the skilled hand under the best illumination of the ear. 
Polypi cannot be removed from the ear by means of the slenderest for- 
ceps. The separation of the blades in the narrow canal is always painful, 
even if the instrument is most slender and delicate, and if the instrument 
is of the latter description it could not maintain a hold upon the slippery 
polyp, even if it by chance obtained it. 

The polyp having been examined with a probe to determine where its 
pedicle is attached, a loop a little larger than the polypus should be 
formed at the end of the canula. Generally a polypus in the fundus of 
the canal will lie over the membrana tympani. In such a case the loop 
may be turned nearly at right angles to the canula, so that it can be 
placed over the polyp without the canula' s interfering with a view of the 
operation. Now a gentle traction on the trigger will draw the loop into 
the canula and constrict the pedicle. The polypus is almost always re- 
tained in the tightened loop and is removed with the instrument. If it is 
not, it can be syringed from the ear or drawn from it with slender forceps 
or a cotton-holder. 

If there is another polyp in the ear it will be revealed after the 
removal of the first, and is to be treated in the same way. As it lies 
deeper, it will require more care and skill to snare the inner one. More 
or less hemorrhage follows the removal of aural polypi. This is very 
slight — a few drops — in the removal of small ones. When they are as 



CHRONIC PURULENT OTITIS MEDIA. 



187 



large as a large pea, or still larger, sometimes from a fluidrachm to a 
fluidounce of blood may be lost. In any case this can be quelled by hot- 



FiG. 84. 



Fig. 83. 




Polypus snare. 



Polj-pus hook. 



water injections into the ear. After the bleeding has ceased and the ear 
been cleaned, search should be made for the former attachment of the 



188 DISEASES OF THE EAR. 

polyi^us. When this is found, if it is large, it should be bitten off with 
tweezer-like forceps, or ^' jaws'' made to work in the foreign-body forceps 

of the Sexton pattern (Fig. 85). If it is too small 
Fig. 85. to seize in any way, it should be touched with 

chromic acid in the manner already described 

(page 184). 
Tweezer forceps. After the point of attachment of the polyp 

has been carefully touched with chromic acid, 
some antiseptic powder, preferably that composed of boric acid and calen- 
dula (page 182), should be blown into the fundus of the canal, and the 
ear let alone for twenty- four hours. The next day the ear should be 
examined, and, if the powder is found to be dry in the fundus of the 
canal, it should be let alone until the next day, or until discharge reap- 
pears. Sometimes this does not reappear, the removal of the polypus 
being followed by entire cessation of the otorrhoea. 

If, however, discharge reappears, the ear must be mopped and ren- 
dered as aseptic as possible. Then the seat of the operation must be 
dried with absorbent cotton and examined to see whether there are any 
traces of the pedicle. If the polyp has been a large one, the cut surface 
of its pedicle may require another touching with chromic acid in the 
course of two or three days, or whenever the whitish slough is detached 
and the red surface of the cut pedicle can be distinctly seen. Then the 
same antiseptic powder is to be blown into the ear and the same course 
of treatment pursued until all trace of the polypus has gone. If the dis- 
charge continues after the disappearance of the polypus, it is to be 
treated as an ordinary uncomj)licated otorrhoea. 

Excision of the Membrana and Ossicula. — It must be borne in mind that a 
perforation in any part of the membrana tympani is only a symptom of 
a deeper disease. On the whole, it is beneficent : it facilitates drainage 
and medication of the middle ear, and is nature's indication of the path 
of treatment to pursue. This is the further removal of the diseased mem- 
brana and the two larger ossicula or their remnants, if antiseptic and 
aseptic treatment alone fail to cure the disease in the drum- cavity. 

When the membrana is in a normal condition it holds the malleus in 
a proper state of isolation from the incus and favors the transmission of 
sound-waves. When, however, it is perforated it becomes retracted, as 
stated above, and permits retraction of the malleus and incus and impac- 
tion of the stapes in the round window. Its inner surface being inflamed, 
as it always is in chronic purulency, and studded with granulations, it 
blocks the drum -cavity and favors further septic retention. If the per- 
foration is small, medication through it is dif&cult and imperfect, and the 
surgical removal of the membrana and malleus is as much indicated as 
that of a polypus or diseased tissue and necrotic bone anywhere else. In 
all cases of chronic purulency of the drum-cavity the malleus and incus 
will be found more or less invaded by caries. The stapes resists this pro- 



CHROXIC PURULENT OTITIS MEDIA. 189 

cess a long time. Therefore, if antisepsis fail to check chronic purulency 
in the drum- cavity, it is irrational and contrary to the teachings of 
modern surgery not to excise the necrotic elements, thus favoring drainage 
and also a more perfect medication of the diseased mucous membrane in 
the drum-cavity. If the stapes has not been invaded by necrosis so as to 
destroy its foot-plate, the hearing will be improved to a greater or less 
degree by this operation, even if the rami of the stapes are gone. With 
the drum- cavity thus cleared, medication, if it has not been too long 
deferred, will prevent extension of purulency and necrosis to the antrum, 
the mastoid region, and the vital parts beyond. Like other successful 
treatment, it is prophylactic of more serious evils. 

Ossiculectomy. — In performing ossiculectomy in chronic j)urulent otitis 
media the patient should be etherized in order to prevent his suffering 
and to keep him perfectly still ; movement of the head defeats the opera- 
tion. Ossiculectomy has been performed under local applications of co- 
caine, but the anaesthesia is not total and the patient flinches or moves 
more or less. Again, as a good deal of cocaine solution is required, there 
is some risk of toxic effects. The patient being under ether, the ear 
must be illuminated bv an electric lamp held on the surgeon's head 
(Fig. 55). 

The remnants of the membrana, over the region of the incus-stapes 
joint, should first be cut away (if not already eroded by disease and the 
malleus in i^art or in whole is still i^resent) and the incus looked for. 
Sometimes the entire incus will be found in position, with its long pro- 
cess in connection with the stapes-head and its body still in articulation 
with the head of the malleus. But this is the exception in chronic puru- 
lent otitis media. Most frequently the incus is entirely destroyed by 
caries. Sometimes the body of the incus, without its long limb, is found 
fused with the malleus-head, and is removed with the latter, when the 
malleus is seized with forceps and removed from the drum-cavity after 
severance of its suspensory ligaments, synechite, etc. In other instances 
the body of the incus is partly destroyed hj necrosis, its jDOsterior i)art 
being intact and the long limb still attached to the stapes. If the incus 
is present with the malleus, the former should be removed before the 
malleus is disturbed. If the malleus is removed first, the incus, unless 
adherent to it, may fall into the lower posterior part of the drum-cavity 
and be lost, or recovered only after considerable, and probably irritative, 
grappling. The incus being found and removed, the malleus may then 
be excised. Sometimes the remnant of the incus is not found until after 
the malleus is removed. Then with an incus hook-knife (Fig. 77, 4) 
I)assed into the attic the incus is thrown forward and downward into the 
atrium and removed. In no case of chronic purulent otitis media should 
the stapes be removed, or even mobilized, for fear of opening the oval 
window and inviting the entrance of pus into the internal ear and thence 
into the cranial cavity. 



190 DISEASES OF THE EAR. 

The initial incision in the membrana may be made with a sharp- 
pointed knife (Fig. 77, 2), but further cutting should be made with a 
blunt-pointed one (Fig. 77, 1). The incus is best detached from the 
stapes by means of the incus hook-knife (Fig. 77, 4), and if adherent to 
the attic should be turned forward into the front and lower part of the 
drum-cavity by means of an incus hook-knife with a longer and blunter 
blade than that for detachment of the incus from the stapes. When the 
incus is entirely freed from its attachments it may be drawn from the 
drum- cavity by the blunt incus hook-knife or by means of the foreign- 
body forceps of Sexton's pattern (Fig. 85). 

In no case should the drum-cavity be curetted, as such a procedure is 
very likely to wound the facial nerve and induce facial palsy. It is, 
furthermore, unnecessary, as, under ];)roper antisepsis, granulations will 
disappear and denuded bone surfaces be covered in with new membrane. 

After removal of the diseased remnants of the membrana and ossicles 
the ear should be mopped with an antiseptic like alcohol or a solution of 
bichloride (1 to 5000) or formalin (1 to 1000), the meatus stopped with a 
light tampon of sterilized gauze, and the ear let alone for twenty-four 
hours. If the gauze in the ear becomes moist with blood or bloody serum, 
it should be removed and a dry dressing put in the meatus not far in the 
canal. In all cases the discharge diminishes at once, and ceases entirely 
in the majority of cases within a period ranging from one to eighteen 
months. The after-treatment should consist in mopping the discharge 
from the ear and the instillation of a formalin solution (1 to 1000) from 
once a day to once a week, according to the quantity and frequency of 
the discharge. The hearing improves to varying extents, the general 
health of the patient is rendered better, and he is freed from the danger 
of extension of the suppuration to the mastoid and cranial cavities. 

If all of the foregoing methods fail to cure uncomplicated chronic 
purulent otitis media, — chronic otorrhcea, — the surgeon should resort to 
the so-called radical operation on the middle-ear cavities, — i.e., upon the 
tympanic cavity, aditus, and antrum. This consists in detaching the 
auricle from the upper posterior bony wall of the external auditory canal, 
drawing the auricle or auricular flap forward, and then, if the bone be 
intact, removing with the chisel or gouge the scute, the outer wall of 
the aditus, and that of the antrum. This operation makes one cavity of 
the external auditory canal, drum-cavity, aditus, and antrum. After all 
diseased tissue is thus removed, the new-formed cavity must be epider- 
mized or cornified before a cure can be said to be secured. In the after- 
treatment of the retro-auricular wound I cannot advocate the maintenance 
of a retro-auricular opening until the new- formed cavity is dermized by 
treatment applied through this opening. After this is done, the retro- 
auricular wound may be closed by a plastic operation ; or it may be left 
permanently open, as some surgeons prefer, in order that the new-formed 
cavity may be inspected as desired. Others prefer, after all diseased tissue 



CHRONIC PURULENT OTITIS MEDIA. 191 

is thoroughly removed from the middle-ear cavities, to let the wound fill 
with a blood-clot, and then bring the edges together, firmly suture, and 
seek for union by first intention. The subsequent treatment for corni- 
fication rather than dermizing the new-formed middle-ear cavity is to be 
conducted through the external auditory meatus. As the drum-cavity, 
aditus, and antrum are mucous-lined, the processes of nature in healed 
cases indicate the advisability of trying to cornify the mucous lining, 
after resection of carious bone from these regions, rather than endeavor- 
ing to line it with true skin. Skin in such a cavity is heterotopic, and 
observation shows that nature does not adopt this method of healing a 
suj)purating ear. 

Exuberant granulations in the new- formed cavity are to be kept down 
by the judicious use of chromic acid. When the granulating surface 
becomes smooth and jialer, the process of cornification, or epidermizing 
of the walls of the new cavity, may be advanced by the insufflation of a 
powder of ichthyolized boric acid (ten per cent.), or one of silver nitrate 
and boric acid thoroughly pulverized (twenty grains to the ounce). 

CHRONIC PURULENT OTITIS MEDIA, AVITHOUT EXTERNAL SYMPTOMS, IN 

YOUNG CHILDREN. 

Grave Diseases in Young Children are often due to Latent and TJnsicspected 
Chronic Inflammation of the Middle Ear. — The importance of this subject 
to the physician and the danger to the child lie in the latent and unsus- 
pected existence of subacute or chronic purulent otitis media. When 
there are objective or subjective symptoms of ear disease in a young 
child, the attention of the medical attendant is called to the existence of 
an ear disease in the case, even if the ear is not treated ; but if there are 
no such symptoms in an ill child, naturally even a grave disease of the 
middle ear would easily escape detection. That just such oversight 
occurs in young children, with fatal results, has been pointed out most 
forcibly by Ponfick,^ Simmonds,'^ and E. H. Pomeroj^^ 

It has long been known that of all middle ears examined in infants, 
dead from any asserted cause, normal ones are a rarity, a large propor- 
tion being found to be the seat of supj)uration, unsuspected and unre- 
vealed until the autopsy, as may be learned from the writings of von 
Troeltsch, Schwartze, Wreden, and others ; but that the latent ear disease 
had caused the fatal general malady in most instances was not suspected 
until Ponfick, of Breslau, in 1897, had his suspicions aroused that in his 
own children there existed a causal relation between suppuration of the 
middle ear and severe gastro- enteritis. He suspected that the ear disease 
was the cause, not the effect, of the general malady. Upon curing the 

^ Berliner Klin. AVochenschr., September and October, 1897. 

2 Archives of Otology, October, 1898. 

' Boston Med. and Surg. Jour., January 18, 1900. 



192 DISEASES OF THE EAR. 

supx^uration of the middle ear. his children rapidly recovered from 
gastro- enteritis without other treatment. 

Being professor of pathology in Breslau, Ponfick at once began, in 
one hundred consecutive cases, an examination of the middle ears of dead 
infants under three years of age. In this series death was attributed to 
various causes. In the entire series of one hundred cases, in less than 
nine per cent, had there been a spontaneous rupture of the membrana 
tympani or any other so-called external symptom of ear disease. None 
of them had been supposed to die of disease connected in any way with 
aural inflammation, unless, perhaps, the six cases tabulated as otitis 
media be excepted. Yet in one hundred individuals there were one 
hundred and sixty-eight diseased tympana, — viz., seventy-seven ambi- 
lateral (one hundred and fifty- four tympana) and fourteen unilateral. In 
Ponfick' s opinion, these children had in most instances died of disease 
originating in what may be termed in a general way a symptomless 
chronic aural suppuration, — that is, there had been no pain in the ear, 
no discharge, nor any external ear symptoms. 

The figures of Simmon ds ^ are still more alarming. In one hundred 
and thirty- three autopsies in nursing infants the middle ear was free from 
exudations in only five cases. He holds that more or less serious lesions 
of the kidneys are found in all forms of i)edatrophy in nursing children, 
and that these are in most instances due to otitis media. Systemic infec- 
tion is more easily brought about from the young child's ear than from 
the adult's, because the middle and internal ears are just as large in the 
new-born child as in the adult, though not at first surrounded by dense 
osseous tissue, as in the adult bone. 

An osseous external auditory canal does not exist in a new-born child 
(Fig. 9). Its little auricle is practically attached by a fibre- cutaneous 
canal to its annulus tympanicus, from which, with the squama, is formed 
the osseous external auditory canal, about half its natural length being 
attained at twelve months and its full length at six years. At birth, how- 
ever, the membrana tympani of the young child is just as large as the 
adult's, but much thicker, and continues so for many months. This fact 
may explain the infrequency of spontaneous rupture of the membrana 
tympani in otitis media in early childhood. Therefore^ in the middle 
ear, for reasons just given, there is an almost vital organ in the young 
child. That serious inflammation of the middle ear in an infant exists 
without much, if any, pain may, perhaps, be accounted for by the fact 
that enough pus may escape from the drum -cavity into the nasopharynx 
through the short, wide Eustachian tube of a young subject to relieve 
tympanic pressure and prevent pain in the ear. This escape of pus into 
the nasopharynx further explains the infrequency of spontaneous perfora- 
tion of the membrana in young subjects affected with otitis media. 

^ Log. cit. 



CHROKIC PURULENT OTITIS MEDIA. 193 

It lias become very clear to many minds that the reason so many 
young children die is because the real origin of their fatal maladj-— a 
middle-ear inflammation — is unrecognized and therefore untreated. If an 
eye is bloodshot, any one can see it ; but if a membrana tympani is con- 
gested and bulging with pus behind it, it requires an expert to detect it. 

Treatment. — It has been shown by Ponfick and others that a latent 
and unsuspected, and hence untreated, otitis media is very often finally 
the cause of a fatal disease in young children, attributed, however, to 
something else. Such an unsuspected otitis media is practically symp- 
tomless until the membrana tymx:)ani is inspected, when the latter will be 
found presenting evidences of inflammation in the drum- cavity beyond, 
— viz., redness and bulging. 

According to some observers, there is otitis media in aJl grave diseases 
in young children, and, this being the case, it becomes the duty of every 
practitioner in attendance vq)o\\ an ill infant or young child to make an 
examination of the membrana tj^mpani as much a part of his routine ex- 
amination as inspection of the tongue. The physician must not wait for 
^^ external symptoms," like otorrhoea, etc. If the ear is examined, the 
membrana tympani in many cases will be found to show signs of accumu- 
lation of secretion behind it in the tympanic cavity. If, now, the mem- 
brana tympani is incised and the pent-ui) secretions allowed to escape, 
symptoms attributed to brain, bowel, or lung diseases will suddenly van- 
ish and the child speedily recover. So important are these facts that it 
is evident that the physician who cannot examine the infant's mem- 
brana tympani, diagnose a tympanic sui^i^m-ation, and relieve it by para- 
centesis is unfit to act as a specialist in children's diseases. 

Barth ^ says that '^ we can conceive of the reasonableness of a daily 
examination of the ears of all unwell infants, from the beginning of their 
illness to the end of convalescence.''' This, in my o^iinion, is asking of 
the general i^ractitioner an impossibility, because, as a rule, he receives 
BO instruction in such matters in his medical school. If instruction in 
otology is given the medical student without requiring any knowledge of 
this subject in his examinations for a degree, he will never learn any- 
thing about otology. The medical student never has learned anything 
not required at the final examination, and never will. He cannot be 
blamed for this, because he naturally regards as unimportant that upon 
which his teachers do not examine him for his degree. 

Intelligent inspection of the membrana tympani is not an easy thing 
to learn. I heard Gruber, of Vienna, say, in 1871, that he would not 
accept the statement of a physician regarding the condition of the mem- 
brana tympani until such a one had examined a great many membranse 
every day for a year. It is only by such experience that an examiner 
of the membrana can interpret what he sees upon this important organ. 

^ Archives of Otology, October and December, 1899. 
13 



CHAPTEE XYIII. 

SEQUEL.E OF CHROXIC PURULENT OTITIS MEDIA. 

Among the earliest x^rominent and grave sequelae of chronic purulent 
inflammation of the middle ear may be named facial paralysis, cholestea- 
toma, and chronic mastoiditis. Later there may occur deeper intra- 
cranial lesionSj which will be considered in subsequent chapters. 

PARALYSIS OF THE FACIAL NERVE IN EAR DISEASES. 

Very often there are anatomical peculiarities in the middle ear favor- 
ing facial paralysis. Into the etiology enter (1) exposure to cold ; (2) 
local diseases of the entire organ of hearing, such as diseases of the auri- 
cle and auditory canal, diseases of the middle ear, like serous and mucous 
catarrhs, acute purulent otitis media, and especially chronic purulent 
otitis media ; (3) traumatism ; (4) new growths in the organ of hearing ; 
(5) tumors at the base of the skull ; and (6) paralyses resulting from 
intracranial lesions of otitis. 

Concerning the anatomical and histological changes in the facial nerve 
occurring in paralysis thereof very little is known. The changes that 
have been demonstrated are hyperaemia and swelling of the neurilemma 
from infiltration and growth of connective tissue, purulent infiltration of 
the neurilemma and of the facial nerve in purulent inflammation of the 
middle ear and caries of the walls of the drum-cavity, atrophy of the 
facial nerve, absorption thereof in consequence of induration and com- 
pression or through pressure from hyperostosis of the facial canal, de- 
generation from induration of the nerve, and total destruction of the 
nerve. 

Symptoms. — Paralytic symptoms in the tract of the facial nerve are 
more marked in peripheral than in central affections of the nerve. As 
prodromes of facial paralysis may be named pain in and behind the ear 
and corresponding side of the face, in the line of the auricularis magnus 
nerve and second branch of the trigeminus. Sometimes there are tinni- 
tus aurium and abnormal sensations of taste. The paralysis may afl'ect 
all or only some of the branches of the facial nerve. A frequent symp- 
tom is paralysis of the soft palate on the affected side. This symj)tom 
has never been explained, as the experiments of Eethi (1893) show that 
the soft palate is innervated by the vagus. Facial paralysis in aural 
diseases begins either by degrees or with marked variations. In some 
cases total facial paralysis comes suddenly, either with or without pro- 
dromes. Lessening of the paralysis is indicated by improvement in cer- 
tain branches first, followed later by others. Eecovery may never occur 

194 



"sr^' 




V _-^ 









"^^^ 




z-^^m^- 







SEQUELvE OF CHROXIC PURULEXT OTITIS MEDIA. 195 

in some brauclies, as, for example, in that of the nasolabial fold or of the 
levator palpebrarnm. In children, facial paralysis may lead to arrest of 
develoi3ment of the face and sometimes to atrophy of its muscles. 

Diagnosis. — The diagnosis of facial paralysis is not difficult, on account 
of the distortion induced. Differential diagnosis between central and 
perii)heral iDaralysis is not easy to make in the early stages and in the 
absence of any objective lesion in the organ of hearing. 

Frognosis. — The i^rognosis is more favorable in children than in adults, 
and in acute than in chronic inflammation of the middle ear. In acute 
cases the prognosis will be influenced by the general condition of the 
patient, being unfavorable in the otitis of the tuberculous, syphilitic, and 
cachectic. A favorable prognostic sign is the return and continuance of 
the normal reaction of the nerve under the application of the constant 
electric current. Discouraging symptoms are extinction of the galvanic 
reaction and atrophy of the muscles of the face. Loss of the perspira- 
tory function of the paralyzed side of the face indicates atrophy of 
the nerve (Tomka). Facial paralysis with necrosis of the labyrinth, 
together with exfoliation of the cochlea and portions of the semicircular 
canals, is often evanescent. When accompanied by exfoliation of the 
internal porus acusticus with necrosis of the entire labyrinth, it is, with 
few exceptions, i:>ermanent. 

Treatment. — The treatment of facial paralysis must be in accordance 
with the cause, the duration, and the seat of the lesion. Tlie apxjlication 
of electricity in acute cases is not indicated until jmin, S2)asm, and all si/m})- 
toms of reaction have disajyj^eared, because l)\j too early an axypUcation of the 
galvanic current the condition of the nerve may he made worse. When elec- 
tricity is applied it should he in the form of a weak constant current through 
the mastoid fossa of the auricle, every other day, from two to three minutes. 
Facial paralysis occuiTing in chronic purulent otitis media calls for both 
medical and surgical treatment of the underlying causative disease in the 
middle ear. Electricity does less good in chronic than in acute otitis. 

Facial Faralysis occurring in a Case of Acute Otitis Media Tuberculosa. — 
On April 10, 1900, Benjamin F., forty-seven years old, an employee in 
an ice factory, stated that about March 23 previous he was attacked by a 
heavy cold 5 that in a week he exi^erienced pain and deafness in the 
right ear, the membrana tympani of which soon spontaneously ruptured 
and the ear discharged pus, the pain ceasing. At the end of the second 
week of his ear disease he observed that the right side of his face was 
twisted towards the left, and he then presented himself at the Presby- 
terian Hospital for treatment (Plate lY.). 

When first seen by me he was in the fifth day of his facial paralysis, 
which was total, even the tij) of his nose being drawn towards the left. 
He complained of headache and malaise. Upon insi3ection of his ear, it 
was seen that a slight purulent discharge was running from the meatus 
and that the entire membrana, including the malleus, was destroyed. 



196 DISEASES OF THE EAR. 

The chorda tympani nerve was observed running in its normal course 
across the upper i)art of the x)lane of the annulus tympanicus^ on its way 
to the Glaserian fissure. In the region of the aditus there was a bunch 
of red granulations very sensitive to the touch, in which was embedded 
a movable piece of bone, resembling a part of an ossicle, and which 
proved to be the long limb of the incus, to which was still attached the 
processus lenticularis. The entire inner surface of the drum-cavity as 
far as could be seen and felt was snow-white and denuded of muco-peri- 
osteum. Manipulation of the chorda tympani in its pink sheath of 
mucous membrane caused a pricking sensation in the man's tongue. The 
sense of taste was better on the left side. The facial palsy was so great 
as to render the patient's speech indistinct, from the clinging of the cheek 
to the jaws. The man had received no treatment before he came to the 
hospital. After his admission to the hospital his ear was kept clean by 
syringing once or twice daily with warm bichloride water 1 to 10,000, 
and later with a solution of 1 to 5000. The discharge from the ear became 
less, but very offensive in odor, suggesting that of necrotic bone. In fact, 
about a month after his admission, a dark rough sequestrum, filling the 
region of the aditus and attic, made its apiDcarance. This was movable 
with a probe, and when thus manipulated a little blood oozed from about 
its sides and the patient was made to feel very uncomfortable. This 
proved to be the rest of the incus. 

From May 16 to 31 the man failed rapidly ; emaciation, evening rises 
in temperature, night-sweats, and cough set in, with development of a 
painful tubercular ulcer in the region of the left half-arch and posterior 
pharyngeal wall. From this period up to June 23 he had numerous 
slight hemorrhages (half a fluidounce) from his right ear. These appar- 
ently came from the region of the jugular bulb and floor of the tym- 
panum. On June 23 tubercle bacilli were found in his sputa, and he was 
removed from the surgical to the medical ward. Here both apices and 
the middle lobe of the right lung were found to be consolidated. Owing 
to extreme weakness, the patient was now obliged to remain in bed ; his 
aural and facial condition remained unaltered. 

About once a week during July there occurred a hemorrhage of about 
half a fluidounce from his right ear. On the evening of August 9 he 
had a hemorrhage of at least a pint from his ear, after which the patient 
sank rapidly, dying on the 10th of August from tubercular exhaustion. 
It was not possible to obtain a post-mortem. Judging from their color 
and recurrence, it is probable that the hemorrhages came from the jugu- 
lar bulb. Carotid hemorrhage would have been redder, solitary, and 
immediately fatal. 

Facial Paralysis in Chronic Purulent Otitis Media. — In Plate Y. is shown 
a case of facial paralysis occurring in chronic purulent otitis media as a 
result of violent treatment by inexpert hands, and resembling somewhat 
a traumatic palsy of the facial. Soon after the violent syringings and 



SEQUET..E OF CHRONIC PURULENT OTITIS MEDIA. 197 

probings were discontinued, and the mucous membrane of the drum- 
cavity near the facial canal gently mopped with formalin solution (1 to 
1000) once daily, the i^ain in the ear and the vertigo ceased, and the 
facial palsy of the face vanished in the course of a month. 

Chronic supijuration of the middle ear advances by the successive 
stages of ulceration of the muco-periosteal membrane, periostitis, ostitis, 
caries, and necrosis of subjacent bone. The interval between the acute 
stage and these successive chronic stages varies greatly in length. In 
some instances the acute stage is rapidly succeeded by all the others, even 
the necrotic exfoliation of some of the parts of the internal ear, while in 
others many years elapse before the chronic suppurative i)rocess in the 
muco-periosteal lining of the drum-cavity seems suddenly to induce caries 
and necrosis of the bone beneath, meningitis, encephalitis, sinus-throm- 
bosis, pj^aemia, and death. 

CholesieatomcL — Cholesteatoma of the middle ear and deeper parts of 
the petrous bone may be i)rimarj^,^ but it is most commonly the result of 
long-continued suppuration in the middle ear. It consists in a collection 
of quite densely packed laminated epithelial cells, undergoing fatty de- 
generation and intermingled with numerous cells of cholesterin. In some 
instances these cells are contained in a kind of cai^sule of connective tis- 
sue."^ This accumulation of cells, resembling those of the epidermis, in- 
terferes quickly with the escape of the newer cells forming beneath its 
inner strata, and thereby increases the impaction and pressure of the 
mass upon the mucous membrane and the underlying bone. This leads 
to ulceration of the muco-periosteal membrane, the formation of granula- 
tions, absorption or erosion of the bone, and the invasion of deeper parts 
of the cranium. 

Treatment. — In many instances cholesteatomatous masses may be 
syringed from the ear by means of warm water. If they are too dense 
to be removed in this manner, they must be softened by instillations of 
hydrogen dioxide or of a mixture containing sodium bicarbonate, gr. xx ; 
glycerin, fgii ; and water, fsvi. These should be instilled a little while 
before syringing and allowed to lie in the ear. Then the syringing, with 
gentle and patient picking with a probe, will dislodge the mass, or that 
part of it which is in the external canal and drum -cavity. Impactions 
in the mastoid cells can be reached and removed only by a mastoid per- 
foration. 

StacJce's Operation. — If caries of the attic wall exists and cholesteato- 
matous masses are found in it, the antrum and the mastoid may be found 
to be simultaneously affected with caries and cholesteatomatous collec- 
tions. So convinced is Stacke that attic disease is accompanied by mas- 

^ Lucae, quoted by Schwartze, Pathological Anatomy of the Ear (Green's trans- 
lation), p. 23. 

* Toynbee, Diseases of the Ear, London, 1868. 



198 DISEASES OF THE EAR. 

toid disease, that lie does not first excise the memlbraiia and ossicula and 
wait to see the result before opening the attic and the antrum. He main- 
tains that in the treatment of sui^iDuration of the attic space the latter 
should he laid freely open so as to be thoroughly inspected after the 
removal of the malleus and incus. The method of doing this, as given 
by Stacke/ has also the advantage of enabling the surgeon to determine 
at once whether there is at the same time any disease in the mastoid. 
The method is as follows. An incision is first made through the soft 
parts down to the bone, beginning above the auricle just behind the tem- 
poral artery and running about a quarter of an inch behind the insertion 
of the auricle down to the point of the mastoid process. After the hem- 
orrhage is quelled by ligatures, the skin and periosteum must be dissected 
or pushed up and away from the incision towards the auditory canal until 
the bony meatus is exposed. Then the cutaneo-periosteal lining of the 
osseous auditory canal must be detached from the posterior wall as far 
as the membrana tympani, until the latter can be distinctly seen. The 
entire auricular flap containing the posterior wall of the auditory canal 
should be drawn well forward, and the now exposed fundus of the canal 
and the diseased membrana illuminated by the electric lamp on the sur- 
geon's head (Fig. 55). The membrana tympani and the malleus are 
then easily excised, and the attic laid bare by chiselling away the tym- 
panic process of the squama forming its outer wall. Then the incus is 
to be removed if it is present, and the upx)er back portion of the annulus 
tympanicus and adjacent wall of the auditory canal should be cut away 
so as to expose the aditus and antrum. When the attic, aditus, and 
antrum are thus laid open, i)ermitting a clear view of their interior, es- 
pecially of the tegmen tympani and tegmen antri, carious spots should 
be sought and curetted if found. If there are no further signs of attic, 
antral, or mastoid disease, the operation is done. The wound should be 
allowed to fill with a blot-clot, the edges brought together, and in this po- 
sition held either by sutures or by a pressure-pad. The after-treatment can 
be carried on most successfully through the auditory canal, as the opera- 
tion permits inspection and direct medication of the attic and antrum, and 
affords greatly improved drainage of these formerly obstructed parts. 

Many authorities teach that after cholesteatoma has been removed 
from the mastoid by operation as just described, a retro-auricular open- 
ing should be maintained at least until the former cholesteatomatous 
cavity is lined with true skin. But this is not advisable when the dis- 
eased cavity is not very large. In general it may be said that true skin 
is out of place, heterotopic, in a closed cavity like the mastoid. There- 
fore it appears more rational to treat cholesteatoma in the temporal bone 
by thorough removal of the heterologous mass, and healing the wound- 
cavity from the bottom without retro-auricular opening. 

^ Otological Section, Tenth International Medical Congress, Berlin, 1890. 



SEQUEL.E OF CHEOXIC PURULENT OTITIS MEDIA. 199 

Chronic Mastoiditis. — Chronic suppurative mastoiditis the result of 
chronic suppuration of the middle ear may, like the latter, continue a 
long time without caries and necrosis of either the medial or the lateral 
plate of the mastoid cavity. It may safely be assumed that in every case 
of chronic supi^uration in the drum- cavity there is a concomitant sup- 
puration in the antrum, and sometimes, also, in the mastoid cells. If the 
chronic tympanic supi)uration can be controlled or cured, the lesions in 
the mastoid antrum are also cured at the same time. As has been said, 
ossiculectomy is the best way of curing chronic suppurative otitis and 
warding off or curing antrum disease. However, many cases of chronic 
sui)puration are either not treated at all or improperly treated, and the 
mastoid cavity becomes more inflamed, — i.e.^ its mucous membrane be- 
comes more infiltrated and its drainage defective. 

Sym})toms. — The disease may now take one of two courses, rarely 
both. Pain in the mastoid, with headache and fever, without any ex- 
ternal mastoid symx)toms, may indicate an irruption of pus either into 
the lateral sinus and posterior cranial fossa or forward into the middle 
cranial fossa ; or pain in the mastoid and fever may be followed by ten- 
derness and swelling of the outer mastoid surfiice and spontaneous open- 
ing of the cortex, with escai)e of pus beneath the dense cutaneous tissues 
of the mastoid region. 

Treatment. — An incision should be made and the pus evacuated. The 
osseous surface should then be fully exj)osed and the opening in the bone 
discovered. This should be followed, the bone well chiselled away, and 
the mastoid cavity thoroughly explored, all diseased tissue, both soft and 
hard, being removed. If the inner wall is intact, the cavity may be 
allowed to fill with blood (Blake), the wound drained and stitched, and 
healing by first intention sought. If, at the same time, all diseased 
tissues in the middle ear can be removed, entire recovery from the chronic 
purulency maj^ be expected. If, after exposure of the mastoid and mid- 
dle-ear cavities, a sinus is found leading to the cranial cavity, the mas- 
toid operation is but preliminary to an operation upon the cranial cavity. 
^o operation upon the encephalon for an otitic lesion can be considered 
€omx)lete until the antrum and middle ear have been opened, the path- 
way of disease from the ear to the brain sought and followed, and the 
septic nidus in the druni-cavity and the mastoid permanently removed. 

The operative procedure in opening the mastoid and antrum cavities 
in chronic intramastoiditis, by means of hammer and chisel, resembles 
that described for trepanation of the mastoid in acute mastoiditis. It 
must be borne in mind, however, that in a case of acute intramastoiditis 
in an ear previously free from i)urulency we may find a much thinner 
cortex than would be found in a mastoid the seat of chronic purulency. 
In the first instance it is preferable to choose the point of trepanation at 
the suprameatal triangle and aim at once for the antrum (Fig. 11, id). We 
make no effort to expose the attic and middle ear and disturb the ossicles, 



200 DISEASES OF THE EAR. 

lest we destroy the hearing while arresting the purulency. In chronic 
purulent intramastoiditis, always a result of chronic purulency of the 
drum-cavity, the surgeon in chiselling open such a mastoid should follow 
any spontaneous opening in the cortex already present, or open at a dis- 
colored or softened spot in the cortex, and then aim for the antrum and 
middle ear, thoroughly explore the middle-ear cavities, and remove all 
diseased tissues, including the malleus and incus or their remnants, but 
never the stapes in any case. This bonelet is very resistant to suppura- 
tion, and hence prevents the entrance of pus from the middle iear to the 
internal ear and thence to the cranial cavity. To remove it in chronic 
supiDuration of the middle ear would be to invite the entrance of pus to 
the internal ear and consequent grave disaster. Every mastoid cavity, 
and hence every case of intramastoiditis, varies from all others. The 
surgeon must, therefore, prepare to go slowly, picking his way until he 
has exposed enough of the outer wall of the mastoid to see his way to the 
antrum or to the mastoid cavity before reaching the antrum, as is often 
necessary in chronic intramastoiditis. It is hardly necessary to say that 
no one should attempt a radical operation on the mastoid unless he has 
had ample practice on the cadaver ; and he should also be able to pene- 
trate the cranial cavity by following a septic pathway from the middle 
ear and mastoid cavities, if one exist^, and relieve the nidus in the brain 
cavity. 



CHAPTEE XIX. 

OTITIC EXTRADrPvAL AXD PEEISIXOUS ABSCESSES. 

If the symptoms of otitic intracranial lesion are not grave, the sur- 
geon may tem^^orize in operating ; but if thej are urgent and life be 
threatenedj he should operate at once. In the former conditions the 
mastoid should be opened first, the nature of the otitic disease discovered, 
and the presence or absence of complications in the adjacent parts of the 
temi^oral bone established. If the latter complications exist, the surgeon 
should proceed at once, if possible, to operate for their relief as soon as 
they are discovered by the exploratory operation on the mastoid. If 
they do not exist at that time, he should wait a fe^v days to see the effect 
of his operation on the temporal bone. If there is urgent need of opera- 
tion on the cranial cavity and brain, and the diagnosis is full}' established, 
the surgeon may in some cases first perform a temporary resection on the 
cranium and treat the i^urulent disease in the ear by a later operation. 

Sym2)toms of Otitic Intracranial Lesions. — If optic neuritis is found in 
connection with purulent inflammation of the ear, the diagnosis of ex- 
tension of ear disease to the brain is certain, no matter whether other 
evidence exists or not (T. E. Pooley). But, unfortunateh^, optic neu- 
ritis does not explain the nature of the intracranial lesion. Marked 
optic neuritis alone, occurring in chronic otorrhcea, is sufficient indica- 
tion for Oldening the mastoid, but optic neuritis as an indication for ex- 
ploratory opening into the cranium in otitic lesions can be considered 
only in connection with other symptoms. Its occurrence, however, seems 
to render quite certain the presence of intracranial disease. 

Extradural Otitic Suppuration. — An extradural otitic suppuration is 
one in which the dura is found more or less exposed and forming part 
of the wall of the purulent cavity in the mastoid. Such exjiosure of the 
dura, especiallj^ over the sinus, is so often an accidental discovery at the 
time of a mastoid operation, and is so seldom accompanied by any symp- 
tom leading to its suspected presence, that no special clinical significance 
can be attached to it. ''This form of exposure of the dura must be con- 
sidered the result of erosion of the bone from without inward, rather than 
the result of the eroding action of a true extradural abscess from within 
outward, ui)on the layer of bone dividing the abscess from the mastoid 
cavit3\ This is shown to be the course i)ursued by the disease, from the 
circumstance that the broken-down region in the bone sometimes has 
the form of a flat funnel, the larger circumference of which is directed 
towards the mastoid cavity. When the bone is destroyed as far as the 
dura, especially over the sinus, the surface of the latter is covered with 

201 



202 DISEASES OF THE EAR. 

granulations, forming a protecting wall against the advance of the in- 
flammation. These granulations participate in the suppuration, and 
hence in this sense we may speak of an extradural suppuration, or sup- 
puration of the outer surface of the dura" (Grunert). If, as soon as the 
mastoid cavity is opened, the pus escapes ivith marlced pulsations, the 
surgeon may he sure that the dura beyond is exposed. 

EXTEADUKAL OTOGENOUS ABSCESSES. 

Extradural or epidural otogenous abscesses are collections of pus, of 
otitic origin, between the dura and the temporal bone. Such collec- 
tions of pus form more frequently in connection with acute than with 
chronic purulent otitis media. 

Symptoms and Diagnosis. — As a rule, fever is absent in uncomplicated 
extradural abscess. This is unfortunate for the patient, because his true 
condition may not be recognized. "VYhen fever is present the abscess 
will be found to be, as a rule, extrasinous. It must be borne in mind, 
however, that fever may be due to the aural inflammation and not to 
an intracranial lesion, especially when there is pus-retention in the ear. 
Therefore, whenever in a case of otitis media fever sets in after the ear 
can be excluded as the cause of the rise in temperature, the medical 
attendant is justified in suspecting an intracranial complication. Un- 
complicated otogenous hrain-ahscess can now be excluded, as it produces 
no fever, as a rule. 

Treatment. — As the i^rognosis in expectant treatment is very doubtful, 
and as spontaneous recovery of an extradural abscess of any size has 
never been observed, the only proper treatment is an operative one. 
However, the dif&culty in determining the indication for operating is 
directly the result of the difficulty and uncertainty in making a diagno- 
sis. A positive diagnosis is not made until the mastoid cavity is opened 
and the external pathway thus exposed followed to the intracranial col- 
lection of pus. ^'If in a mastoid operation we find no conducting- 
sinus, we are justified, when we suspect, on the strength of clinical obser- 
vation, the possibility of the presence of an extradural abscess, in not 
hesitating to open the middle and j)osterior cranial fossae and seek for the 
extradural pus" (Grunert). If in such a case no pus is found in the 
middle or posterior fossa it is best to await the result of the mastoid 
operation. If the deep-seated headache and other symptoms which have 
led to the probable diagnosis of the presence of an extradural abscess 
continue after the mastoid operation, one must bear in mind the possi- 
bility that the extradural pus, sought for in vain in the middle and pos- 
terior fossae of the skull, may be on the iDOsterior surface of the pyramidal 
part of the petrous bone or on its apex ; and in such an instance the surgeon 
should endeavor to reach this deep-seated pus- collection by opening the 
cranial cavity immediately above the bony auditory canal and pushing 
away the dura from the petrous pyramid, as suggested by von Bergmann. 



OTITIC EXTRADURAL AND PEKISIXOUS ABSCESSES. 203 

AVbeu tlie extradural abscess is finally reached, it must be opened as 
freely as i:)ossible by chiselling away the overlying bone coextensively 
with the diseased area of the dura. It will not be sufficient to remove 
only so much of the bone as corresponds to that portion of it from 
which the pus has lifted the dura, because the two areas do not always 
coincide, especially in diffuse extradural pus-collections in connection 
with chronic purulent otitis media. Scraping granulations from the 
dura is not advisable when these are of a dirty gray color, because in 
such a procedure, especially when the granulations are located on the 
sinus, even with great care in using the curette, there is danger not only 
of mechanical infection of the soft meninges, but also, when the sinus is 
implicated, of hemorrhage from the latter. Tlie abscess- cavity clears itself 
after it is oiyened and pacl^ed^ so that, as a rule, by the first or second change 
of dressing the dura mater at the bottom of the abscess- cavity assumes 
the aiDpearance of a fresh wound-surface. The results of treatment of 
uncomplicated otogenous extradural abscess, in connection with acute 
otitis media, are extremely favorable (91.7 per cent., Grunert) ; less so 
in chronic cases. Entire cure in these cases of otogenous extradural ab- 
scess includes entire healing of the causative ear disease. 

Deep-lying extradural abscesses, which originate chiefly from irru})- 
tion of pus through the semicircular canals, but sometimes from convey- 
ance of pus along the course of the facial and major superficial petrosal 
nerves, usually have their centre at the point where the i^osterior limbs 
of the vertical semicircular canals unite, and burrow along the upper 
posterior edge of the pyramid, sometimes inward and sometimes outward. 
Nearly all cases of this kind, as obser^-ed by Jansen, originated in acide 
otitis media. 

Treatment. — In such cases the upper wall of the pyramid as far as the 
superior semicircular canal, the posterior upper edge of the same for a 
like distance, and also the adjoining posterior wall should be removed 
with bone- forceps as far as the labyrinth core. In order to insure undis- 
turbed healing and avoid deep burrowing of pus along the acoustic nerve, 
it is best to follow the exposure of deep labyrinth abscesses by opening the 
vestibide. This can be best done by the removal of the posterior half or 
two -thirds of the semicircular canal from behind and above downward 
by means of narrow, straight chisels. If necessary, the lower posterior 
semicircular canal may also be partly or entirely removed and then the 
vestibule laid open, from behind forward, by removing the posterior half 
of the horizontal semicircular canal. 

Ferisinous abscesses have generally been exi^osed by opening the pos- 
terior cranial fossa after chiselling open the mastoid x)rocess. In a few 
instances they have been opened through the middle cranial fossa. In 
cases in which the mastoid abscess and the purulent centres in the sinus 
form one pus- cavity, the latter has been opened and drained by the one 
operation on the mastoid. When this is not the form of the perisinous ab- 



204 DISEASES OF THE EAR. 

scess, the procedure should consist in opening the mastoid and antrum and 
then chiselling away the posterior bony wall of the mastoid cavity until 
the anterior lateral wall of the sinus is brought to view. Then exposure 
of the sinus must be carried on until healthy tissue is reached. Suppu- 
rations about the sinus lying deep in the cranial cavity are reached only 
after removal of the inner and posterior wall of the mastoid in its entire 
extent^ best accomplished with chisels and long-bladed bone-forceps. If 
the abscess extends as far as the jugular foramen, it must be pursued by 
chiselling away the transverse sinus and, when necessary, removal of 
part of the floor of the posterior cranial fossa. If the part of the sinus- 
wall first exposed is free from disease, then the posterior cranial fossa 
must be further opened so as to permit the removal by a raspatorium of 
the sinus and the dura from the posterior surface of the petrous bone. If 
no pus is found here, and yet the symptoms of a iDurulent focus in the 
posterior cranial fossa continue, it is deemed necessary to expose the 
upper knee of the sigmoid portion of the sinus and that part of its pos- 
terior horizontal course near it. If pus then gushes from the middle 
fossa, or if with continuing symptoms of intracranial suppuration the 
posterior fossa is found free from pus, the middle fossa must be opened 
from the cranial surface, i^referably above the linea temporalis. If the 
opening of the middle cranial fossa is begun by removing the lower part 
of the squama, inspection of the entire upper surface of the petrous pyra- 
mid is made easier (Jansen). The initial opening should be made with 
a crown trephine close above the posterior wall of the auditory canal, 
and reach backward and forward for several centimetres as required. 
Bone-forceps are best adapted for the enlargement of this opening. 



CHAPTEE XX. 

OTITIC PHLEBITIS, THROMBOSIS, AXD PY.EMIA. 

Symptoms. — Dilatation of tlie veins of tlie scalp is considered by Ler- 
nioyez^ to be a pathognomonic symi)tom of thrombosis of the superior lon- 
gitudinal sinus. In a case that he reports, '^this dilatation, which could 
be seen only after the scalp was shaved for operation, affected all the 
superficial veins of the skull, in the right as well as the left side, and 
formed a kind of 'Medusa's head,' such as is seen in the belly of old 
cirrhotics." Ojytic neuritis is usually not observed, or only slightly 
marked, in uncomplicated sinus-thrombosis 5 it is sometimes found in con- 
nection with extradural abscess. Headache is usually Avanting in uncom- 
plicated sinus-thrombosis. Bigidity of the Jieck may be found in septic 
thrombosis of the sinus. Difficulty of deglutition, when not dependent upon 
pharyngeal inflammation, indicates thrombosis of the sinus and deserves 
more attention than it obtains ; it is probably more frequently present 
than is supj)osed (Gradenigo). Vertigo and nausea are also observed in 
connection with uncomj)licated sinus-thrombosis. The fever in sinus- 
thrombosis usually assumes the pycemic type ; it may, however, be con- 
stant and not pyaemic in type. The patellar and suijerficial reflexes are 
unchanged in uncomi^licated sinus-thrombosis. 

AMiiting, in his valuable brochure,^ gives three clinical stages of sinus- 
thrombosis, as follows : 

First Stage. — The presence of a thrombus, parietal or complete (chiefly 
composed of fibrin, red blood-cells, exfoliated endothelium, leucocytes, 
and homogeneous protoplasmic cells), not having undergone disintegra- 
tion and accomj)anied by slight or moderate pyrexia, rigors being usually 
insignificant or absent. 

Second Stage. — The i^resence of a thrombus, parietal or com^^lete, which 
has undergone disintegration with resulting systemic absorption, char- 
acterized by fi^equent rigors and pronounced septico-pytemic fluctuations 
of temperature. 

Third Stage. — The presence of a thi^ombus, parietal or comj)lete, which 
has undergone disintegration with systemic absorption, accompanied by 
rigors, rapid and great fluctuations of temperature and central or periph- 
eral embolic metastases, terminating usually in septic pneumonia, ente- 
ritis, or meningitis. 

The diagnosis of the first stage, owing to the indeterminate symptoms 
up to this point, is rarely made until an operation for mastoiditis is per- 



^ Ann. des Mai. de 1' Oreille, December, 1897 
' Archives of Otology, December, 1898. 



205 



206 • DISEASES OF THE EAR. 

formed. In this stage recovery is still possible, though not probable 
without operation upon the sinus, for the thrombus must now be con- 
sidered as infective. The only safeguard against the second stage is to 
operate immediately upon recognition of the first stage. The prognosis 
in the first stage is highly favorable, while in the second stage it is very 
much less so, on account of the systemic affection now present and the 
operative risks. The period of transition between the first and second 
stages is generally brief, and its completion is usually heralded by a sharp 
rigor. 

The diagnosis of the second stage is established by symptoms that can- 
not be attributed simply to a suppurative inflammation of the middle ear, 
but can be dependent upon nothing but an otitic septic involvement of 
the sinus. 

The diagnosis of the third stage is '^to the practical observer distress- 
ingly clear." All the symptoms of the second stage are increased by the 
additional sym^Dtoms resulting from the dissemination of septic emboli and 
the occurrence of embolic metastases. However, even in the midst of 
these symi)toms^ including septic enteritis and acute septic parenchyma- 
tous nephritis, recovery has ta'ken place in some of the cases operated upon 
by Whiting. 

All authorities now deem prompt exploratory exposure of the sinus 
in susi)ected sinus-phlebitis entirely justifiable and much more advanta- 
geous to the patient than waiting for positive symptoms of the presence of 
sinus-thrombosis, when it is generally too late to operate with hope of 
relief. 

Treatment. — The region to be operated upon and its relation to con- 
tiguous aural and cerebral structures may be seen in Fig. ^Q. The pre- 
liminary steps to an operation upon the sigmoid sinus are like those for 
the usual mastoid operation. 

The sigmoid groove may be quickly and conveniently opened with a 
curette or a rongeur, but never with a chisel and hammer. The rongeur 
used for this purpose should be as broad as possible at its beak. The 
most accessible part of the sigmoid groove for opening is the knee and 
descending portion below it. 

The knee lies about at the level of the suprameatal spine, and usually 
from one-half to two-thirds of an inch posterior to it. If the mastoid is 
markedly prominent and convex, it is then what is known as a ''dan- 
gerous mastoid," because the groove for the sinus will be found to be 
superficial, — ie., near the posterior wall of the external auditory canal, 
— while when the mastoid process is broad and flat, the sinus usually lies 
quite far behind the posterior wall of the external auditory canal. After 
the groove of the sinus is opened, further exposure of the sinus either 
way is best accomplished with a rongeur, the chisel and hammer being 
used only to remove the outer table of the skull, which is too thick 
to be removed by means of the rongeur. All carious bone must be 



PLATE YT. 




Diagram of intra- and extracranial venous anastomosis. (Mace-\ven.) 



OTITIC PHLEBITIS, THEOMBOSIS, AND PY-.EMIA. 



207 



removed, no matter how far such interference may lead. Operation on the 
sigmoid sinus cannot be jDroperly performed if less than two inches of 
its bony covering be removed. As much as this should be removed 
Tvhether the bone is diseased or not throughout this length, 

Chipault and Lambotte ^ have removed the bone and the sinus, after 
ligation of the jugular, from the bulb to the torcular, the patient recov- 
ering entirely. Downward, it will serve all purposes to remove the 
groove as far as and including the external margin of the jugular fora- 
men, great care being taken to avoid the posterior condylar foramen be- 
hind and the lower third of the Fallopian canal in front. In most instances 
the thrombus is situated in the descending portion of the sigmoid sinus 

Fig. 8Cy. 




Cast of the middle ear and mastoid, seen from without. (F. Siebenmann.) 1, upper external 
horizontal cells, squamomastoid : 2, anterior upper horizontal cells, squamomastoid : 3, upper malleo- 
incudal space, attic ; 4, external malleo-incudal fold ; 5, lower malleo-incudo-squamous space, lower 
attic ; 6, upper pouch of the membrana , 7, tubal cells ; 8, tympanic cells, floor of drum-cavity over 
the jugular bulb ; 9, Eustachian tube ; 10, petrosal sinus, and 11, transverse sinus, lying together in the 
jugular fossa. 



extending to the knee, rarelj^ far beyond it into the lateral sinus, and 
thence downward towards the bulb, and sometimes farther downward 
into the jugular vein. Knapp observed a case of thrombosis of the left 
lateral sinus which extended all the way around through the torcular to 
the right lateral sinus. 

When the thrombus is incomi^lete or parietal, it is hard to recognize. 
As blood still flows through the sinus, the aspirating needle is of no as- 
sistance. Inspection will not aid. as there is no bulging. Palpation 
must be depended upon, for it will reveal the fact that the sinus-wall will 



1 Ann. des Mai. de T Oreille, 1899. 



208 DISEASES OF THE EAR. 

dimple like a bladder filled with water, and is equally tense in all direc- 
tions. Pressure with the finger-tip over the parietal clot will impart a 
sensation to the finger of contact with ''a thickened tissue under which 
lies an unevenly distributed, yielding substance" (Whiting). 

Before an incision is made in the exposed sinus, it is imperative to 
obstruct the flow of blood both below and above, so that the hemorrhage 
may not be excessive, as it will occur from both directions at the same 
time. The sinus should now be incised in its long axis to an extent suffi- 
cient to admit of the convenient introduction and manipulation of a 
curette, with which the clot should be thoroughly and rapidly removed. 
Some bleeding should be permitted, as it will wash out particles of the 
clot not removed by the curette. Every vestige of clot must be removed 
and the circulation thoroughly re-established, or sepsis will continue, and 
another operation be demanded after the patient has become weaker. 
As the parietal and visceral walls of the sinus may be very close together, 
the initial incision into the sinus must be made cautiously, or the visceral 
wall and the brain may be wounded. After controlling the hemorrhage, 
the entire wound-cavity should be filled with gauze, covered with cotton, 
and a firm bandage applied ; or ' ' gauze may be packed firmly upon the 
opening in the sinus and the flap of the skin wound stitched down upon 
the packing with heavy sutures" (Whiting). The stitches may be re- 
moved in twenty-four hours or later, as demanded by expediency. 

In considering a completely obstructing thrombus at the knee of the 
sigmoid sinus, or in its vicinity above or below. Whiting ^ states that in 
this condition ^Hhe sinus lacks its characteristic smoothness and lustre, 
and is seen to be distended and generally darkly discolored at the site 
of the clot, and granulations may or may not cover the walls. The pres- 
ence or absence of pulsation is of no material significance. The sinus 
has a doughy feeling if the clot is fresh 5 or it is firm, tense, and resisting 
if the clot is older and contains granulations. In such a case the sinus 
should be freely exposed above and below the obstruction, and pressure 
made ux)on it both at the distal and proximal ends of the clot. The in- 
cision must be sufficient to admit easily and freely a small curette. 
When the thrombus is recognized early in its formation, while it is soft 
and non-adherent, a short incision is ample, as the clot will be forced by 
the blood-pressure in the sinus and the elasticity of the meninges behind 
it through the opening thus made. When a small, firm obstruction exists, 
the sinus should be very carefully scrutinized between the clot and the 
bulb, so that any respiratory movements of its walls may be detected, 
for in case of aspiration of the jugular bulb and sinus below the throm- 
bus, danger of aerial embolism is to be apprehended, unless the precau- 
tion of ligating the jugular preliminary to opening the sinus is observed." 
It is said that air embolism of the sinus or jugular may be prevented by 

^ Log. cit. 



OTITIC PHLEBITIS, THR0:MB0SIS, AXD PYEMIA. 209 

covering tlie opening in the vessel with a seal of sterilized water. After 
the removal of the clot the visceral wall of the sinus should be carefully 
examined with a probe, in order to see whether there exists a fistulous 
tract leading to an abscess in the occii^ital lobe or in the cerebellum. If 
the incision in the sinus has been a small one, firm application of a gauze 
pad ui)on it, and on the intact sinus-wall at each side of it, exercises 
sufficient pressure when supported by cotton and tight bandaging. 

In a case of completely obstructing thrombus extending into the bulb 
or involving the jugular vein, or both, the local symptoms are very pro- 
nounced, being an exaggeration of those characterizing a small complete 
obstruction. If sight and touch cannot establish the diagnosis, the asi^i- 
rating needle will give the desired aid, '^for, when thrust into the sinus 
at various points over the suspected area, it will exhibit either pus, serum, 
or nothing at all, as the case may be, but, in any event, no venous blood" 
(Whiting). In this variety of thrombus the incision should begin at its 
distal end, and an endeavor be made to re-establish the circulation from 
the torcular side first. Of course, hemorrhage can, in such a case, occur 
only from one direction, and can be controlled easily by a gauze pledget 
under the left index-finger of the operator. The incision, beginning at 
the torcular end of the clot, should extend downward towards the bulb 
about one and one-half inches. Should the circulation be re-established 
at the time of the incision, it can be controlled by the finger until that 
portion of the clot exposed by this incision can be thoroughly curetted 
and the oi:)euing irrigated with bichloride solution (1 to 5000). Then a 
permanent gauze hiemostat may be placed in position. If the circulation 
is not re-established immediately uj^on incision, or if its flow is scanty, 
tlie incision may be extended farther backward if the oi^eniug in the sig- 
moid groove permits, or a small curette may be introduced into the lumen 
of the sinus and the clot removed by outward and upward movement of 
the curette until rapid hemorrhage occurs. The latter may be momen- 
tarily permitted, ^'thus favoring the expression of any loosely attached 
infective particles that may have eluded the search of the curette" (Whit- 
ing). Then a permanent gauze h^emostat may be ai)plied, as has been 
stated. The first half of the operation for re-establishment of the circu- 
lation is now done. Re-establishment of the circulation from below is 
brought about by extending the original incision in the sinus- wall, either 
with scalpel or scissors, well downward to the bulb, and resorting again 
to curetting. The application should be attended with equal care, but 
with greater vigor than above, the tortuosity of this portion of the sinus 
rendering the attachment of the clot more tenacious and less accessible 
than near the knee, hence the thorough removal is proportionately more 
difficult (^Miiting). When the circulation in this direction is completely 
re-established, the flow of blood is rapid and very coj)ious, so that the 
operator must never be satisfied with a scanty or slow hemorrhage as 
the result of his curetting the bulb, but persevere until he obtains a 

14 



210 DISEASES OF THE EAR. 

copious flow of blood 5 for copious hemorrhage can always be controlled 
by pressure on the jugular in the neck until the curetting is done, after 
which a tampon of iodoform gauze, thrust firmly but not too forcibly 
into the jugular bulb, gives prompt and efficient control. We must 
remember that the jugular foramen gives exit to the eighth nerve, and 
that undue force in introducing the tampon in this region might interfere 
with the functions of the pneumogastric. The circulation being re-estab- 
lished and the gauze packing in position, the visceral wall of the sinus 
lying between the two tampons should be examined with 3> probe, ''that 
any softening or fistulous tract may be detected leading to a subdural 
collection of pus^ or to an abscess in the brain, ^o such complications 
being present, and the sinus-wall intact, the whole should be thoroughly 
irrigated with a solution of bichloride (1 to 5000), and folded strips of 
gauze carefully packed into the bone. The extreme angles of the cuta- 
neous flaxes should then be stitched, leaving, however, an extensive wound 
between them sufficiently long to admit of unembarrassed inspection and 
subsequent dressing. This wound must be filled with gauze, covered 
with cotton, and the apposition maintained by a firm bandage" (Whit- 
ing). Shock is often great after such an operation as has just been de- 
scribed, and for such a complication Whiting recommends, as giving 
speedy relief, " an intravenous saline injection of from sixteen to twenty- 
four fluidounces, introduced at a temperature of from 105° to 108° F., 
through the median basilic vein. ' ' If this cannot be done, a good sub- 
stitute is the ^^ injection into the bowel of a pint or a quart of normal 
saline solution at a temperature of from 110° to 115° F." 

Great embarrassment in diagnosis may arise if the site of the clot is at 
or below the jugular bulb. A patient may exhibit all the symptoms of 
sinus- thrombosis, and yet the sinus, when exposed from the knee to the 
bulb, be full of fluid blood. Whether this comes from the torcular or 
the jugular side is not easy to decide before opening the sinus. In this 
surgical dilemma, Whiting resorts to the following manoeuvre. The left 
index- finger is placed across the sinus at the bulb with sufficient firmness 
to cause obstructive pressure and collapse of the walls at that point 5 the 
right index- finger is then placed close beside the left, and with a stroking, 
stripping movement carried steadily along the course of the sinus 
towards the torcular as far as the knee, at which point the finger rests 
with firm pressure. The result of this x>rocedure is to expel the blood 
from the sinus and leave its walls in a collapsed condition between the 
two controlling fingers. An assistant nov/ makes firm pressure upon the 
jugular vein low down in the neck, so that the backward pressure of the 
blood- current towards the bulb may be as much as possible augmented. 
It is now obvious that, in case no obstructing thrombus exists in the 
vein or sinus, the collapsed wall of the latter would be immediately dis- 
tended with blood upon removing the pressure of either finger. If, after 
expressing the blood from the sinus and collapsing its walls, the finger- 



OTITIC PHLEBITIS, THROMBOSIS, AND PYEMIA. 211 

pressure at the bulb is removed, and the sinus does not refill, it becomes 
plain that the obstruction is in the bulb or below it, in the jugular vein. 
In such a case, the finger-pressure at the knee being removed and the 
sinus being immediately filled with blood, the operator is assured that 
there is no obstruction on the torcular side. In this experiment all ex- 
pressive movements should be made from the bulb towards the torcular, 
to prevent the risk of forcing particles of the clot into the jugular. 

In '^extreme cases" in which infection has extended into the jugular 
and has resulted in sej)tic phlebitis, possibly suppurative in character, it 
will be manifestly impossible to re-establish the circulation in that direc- 
tion. Hence, in order to anticipate or prevent dissemination of septic 
matter, the jugular vein must be ligated as low down as i)0ssible near the 
clavicle and also high uj), as near as i^ossible to the bulb, and the jugular 
resected and removed entire from the neck. The jugular bulb should 
then be syringed thoroughh', but not too forcibly, with a solution of bi- 
chloride (1 to 5000), the stream being directed downward into the bulb 
through the incision already made for curetting. Forcible upward 
syringing from the neck into the bulb maj^ easily wash septic matter 
through its softened visceral wall into the subdural or subarachnoid 
spaces. In this oi^eration, at the moment of opening the sinus-wall the 
foot of the oi^erating-table should be appreciably elevated, in order to 
increase the blood-pressure in the dural sinuses, and thus diminish the 
risks of the admission of air into the open vein. Aspirating puncture of 
the sinus is of little value, even in simi:)le cases ; it is only confirmatory 
of other diagnostic signs. It is valueless in parietal thrombosis and ob- 
struction in the bulb and ui:)per jugular. The operation on the sinus 
always requires plent}' of time for its successful performance. 

The i)lan presented for the exposure of perisinous abscesses may be pur- 
sued in laying bare the diseased sinus. The thrombotic part of the sinus 
should be opened forward and downward until undiscolored thrombosis is 
reached, if necessary as far as the jugular foramen. Backward it is better 
to exx^ose the sinus a few centimetres farther than the thrombus extends. 

Thrombosis of the Cavernous >S'/«i(s.— Koerner has shown that this form 
of thrombosis is due frequently to the j)assage of infection from the mid- 
dle ear, by way of the carotid canal, to the cavernous sinus. The occur- 
rence of oedema about the brow and orbit, exophthalmos, paralysis of the 
ocular muscles, immobility of the eyeball, oedema of the lids, chemosis 
of the conjunctiva, and choked disk on the side of the chronic aural sup- 
puration indicate thrombosis of the cavernous sinus. 

Treatment. — The treatment consists in prom^^t surgical exposure of 
the middle-ear cavities, oi^ening freely the lateral sinus and j)ermitting 
judicious hemorrhage in the hope that the forcible blood-current in the 
sinuses will eject the thrombus either at the artificial opening in the lat- 
eral sinus or throw it into the general circulation, when, if not infectious, 
it may be dissolved without metastases (O. Brieger). 



CHAPTEE XXL 

OTITIC CEREBRAL AND CEREBELLAR ABSCESS AND MENINGITIS. 
OTITIC CEREBRAL ABSCESS. 

Symptoms, — Optic neuritis is frequently found in otitic cerebral ab- 
scess, as well as in extradural abscess. Headache is always present with 
cerebral abscess. Slowness of the pulse may be observed in this disease, 
but is not always present. Fever does not usually appear in cerebral 
abscess until near the end, and is generally high. Patellar and super- 
ficial reflexes are exaggerated in cerebral abscess, especially on the side 
opposite the lesion. 

Small abscesses in the temporal lobes may run their course without 
central symptoms, as shown by Oppenheim.^ Optic acoustic aphasia 
is the usual symptom of abscess in the left temporal lobe. The same 
symptom may be present in abscess in the right temporal lobe of a left- 
handed subject. The diagnosis of an abscess in the right temporal lobe 
is far more difficult than in one of the left, since the physician must be 
guided by the existence or discovery of so-called indirect symptoms or 
symptoms of contiguity. Ptosis of the left upper eyelid has been ob- 
served in connection with an otitic abscess of the left temporal lobe 
(Steinbriigge). The latter symptom is supposed to be due to pressure 
of the abscess upon the trunk of the oculomotor nerve close to the in- 
sertion of the tentorium cerebelli, where it passes beneath the dura, and 
is considered to be a valuable symptom of the presence of an abscess in 
the temi^oral lobe when it occurs on the side of the affected ear. 

Among the symptoms of otitic cerebral abscess may be named vertigo, 
staggering, nausea, dysphasia, violent headaches, and hemiparesis of the 
opposite side, without rise of temperature. Sensory aphasia and homon- 
ymous hemianopsia with preservation of the pupillary reaction points 
to the temporal lobe as the seat of the abscess. Amnesic aphasia is con- 
sidered a symptom of abscess in the left temporal lobe. An otitic abscess 
in the temporosphenoidal lobe may present mixed symptoms, as, for ex- 
ample, aphasic symptoms, those of brain-abscess, in conjunction with 
chills, high temperature, rapid pulse, and convulsions, — i.e., symptoms 
of thrombosis of the lateral sinus rather than of brain-abscess, — as in a 
case reported by G. Bacon. ^ The aphasic symptoms, however, lead to 
the diagnosis of brain -abscess. 

Symptoms of extradural abscess or of sigmoid sinus-thrombosis always 

^ Nothnagel, Spec. Path. u. Therap., 1897. 
2 Transact. Amer. Otol. Soc, July, 1896. 
212 



OTITIC CEREBRAL AXD CEREBELLAR ABSCESS AND MENINGITIS. 213 

dominate and mask those of brain-abscess when they occur together, and 
it is not until the former condition has been relieved that reliable evi- 
dence of the pressure of a brain- abscess can be obtained. Hemiplegia is 
a symptom that the contents of the brain-abscess press upon the internal 
capsule. Involvement of the third nerve is a symptom of temi)oro- 
sphenoidal abscess ; sometimes the sixth nerve is involved in the same 
lesion. 

Nearly all otitic brain-abscesses are situate very near the spot of orig- 
inal suppuration in the middle ear or petrous bone, and often in demon- 
strable connection therewith. Since when the abscess is in the temporal 
lobe the tegmen tymi)ani and tegmen antri are diseased and the abscess 
lies with its fundus against the. dura, it is possible in many instances to 
unite the emptj^ing of the abscess with removal of diseased bone in the 
middle-ear cavities. 

Brain-abscesses may be bicameral, or multiple and discrete. The former 
have been noted in the temporal lobe, and the latter may be, one in the 
temporal and one in the occi^^ital lobe of the saoie side. Usually their 
existence in either form is not discovered until an autopsy. Multiple 
discrete abscesses may occur in the cerebellum, — viz., one in the right 
lobe and one in the processus vermiformis (Heiman). 

In bicameral cerebral abscess a fistula may be found communicating 
with the ventricle and associated with optic aphasia. Manasse ^ records 
such an occurrence in a woman of forty- two, the subject of chronic puru- 
lency of the ear, successfully relieved by oj^eration. Spontaneous ex- 
ternal discharge of a cerebral abscess may occur, as reported by TJrbant- 
schitsch.^ The discharge took place through the tegmen tympani, the 
middle ear, and a mastoid opening. 

Sudden vertigo, titubation, intense headache, hemiparesis, aphasia of 
conductibility without verbal deafness, and lateral homonymous hemi- 
anopsia on the affected side, with conservation of x^upillary reflex in a 
subject of chronic purulent otorrhoea, have been shown to be symptoms 
of an otitic abscess in the occipital lobe (Lannois and Joboulay). Ac- 
cording to these authors, the aphasia of otitic cerebral abscess is oftener 
an aphasia of conductibilit}^ than a pure motor ai^hasia. 

A bicameral otogenous abscess may occur in the occipital lobe, as 
shown by J. Morf,^ and a sim^ile otogenous abscess of the occipital lobe 
may mixture into the lateral ventricle, paralyzing the breathing centre, 
as reported by Grunert.^ In this the slow pulse did not appear till near 
the end, as there had been continued fever from the cerebritis about the 
abscess. 



^ Arch. f. Otol., April, 1898. 

2 Austrian Otol. Soc, November 30, 1897. 

3 Arch. f. Otol., July, 1897. 

^ Arch. f. Ohrenh., December 30, 1897. 



214 DISEASES OF THE EAR. 

Histological Seat. — In seeking an explanation of the great variety and 
difference in the symptoms of brain -abscesses we must first bear in 
mind the histological seat of the abscess, — i.e., whether the abscess is seated 
in the Irain-tissue itself or in its connective-tissue framewo7^Jc : also whether 
we have before us in a given case a breaking down of brain- tissue, a 
destructive process, or a collection of new-formed pus in the connective- 
tissue framework of the brain, — i.e., ap7'oductive process/ This leads at 
once to the classification of brain -abscesses into two kinds, — viz., the 
parenchymatous and the interstitial. The first form is really an abscess of 
the brain ; the second is an abscess in the brain. The xxirenchymatons 
hrain-abscess must be considered the result of a purulent breakdown or 
gangrenous destruction of the brain substance, — a degenerative or de- 
structive process induced by the incursion of infectious matter from the 
sui^purating ear. The contents of such an abscess are not true pus, but 
ichor. 

The interstitial brain-abscess is the product of an inflammatory x)ro- 
cess set up in the interstitial connective tissue by pathogenic germs 
coming from the aural suppuration. It is therefore a ' ' productive or a 
formative, or an exudative process," and inflammatory new formation and 
increase of this connective tissue, with escape of pus-cells into the in- 
flamed region and consequent formation of a new focus of pure i^us, are 
characteristic of this condition. In a parenchymatous abscess, therefore, 
something previously present is destroyed or transformed, whereas in an 
interstitial abscess something not heretofore existent is formed and added 
to the normal contents of the cranial cavity. 

Why the irritants arising from the neighboring aural sup^Duration 
sometimes produce a parenchymatous and sometimes an interstitial brain- 
abscess depends probably uj^on the Jcind of invading irritant. If this 
belongs to the class of pus-producing cocci, an interstitial supiDuration 
will be the result of its invasion of the brain ; if the bacteria of decom- 
position pass from the ear to the cranial cavity, gangrenous destruction 
in the part invaded by them will be the result. The contents of the paren- 
chymatous abscess possess great fetor, being ichor ; the contents of the in- 
terstitial abscess, being pus, are odorless, or nearly so. The interstitial 
abscess has a connective-tissue membrane or capsule. The parenchyma- 
tous abscess has no connective- tissue capsule, but at best is surrounded 
only by an infiltrated thick wall not separated from the adjacent brain 
substance by any connective tissue. Such a surrounding wall might be 
termed an ' ' ichorogenous' ' membrane. These differences in the nature 
of the surrounding walls of the two kinds of brain-abscess account for 
certain clinical differences observed in the two kinds. 

Fever. — The parenchymatous abscess runs its course ivithout fever, since 
its occurrence is not a true inflammatory process. In fact, there may be 

1 R. Miiller, Arch. f. Ohrenheilkunde, September 20, 1900. 



OTITIC CEREBRAL AND CEREBELLAR ABSCESS AND MENINGITIS. 215 

vitli it siibuormal temperatures, as is often observed in brain- abscesses, 
or there may occur, wlien the ichorous matters get into the lymph, and 
blood-channels, fever of a markedly ichorsemic or septicsemic character, 
as is also sometimes seen in brain-abscess. 

An interstitial brain -abscess, however, being the result of an inflam- 
matory process, is always accompanied by fever, which, however, in 
consequence of the small extent of the inflammatory focus compared to 
the size of the entire body, is only slight, and if there are no other 
fever-producing factors present, it will be limited to an evening body 
temperature of 37.2°, 37.8°, or 38° C, as is often observed in cases of 
brain- abscess. 

Brain- Pressure. — The most important difference between both kinds 
of abscess lies, however, in the symptoms of increased brain-pressure. As 
the interstitial brain-abscess is attended with the formation of new ele- 
,ments in the brain, the latter remaining undiminished, it must be attended 
at once with increase Of intracranial i)ressure, whereas the parenchyma- 
tous abscess being formed by the breaking down of brain-tissue and the 
assumption of the place of the destroyed brain by ichorous material, the 
latter equals the quantity of the former, the brain space is not encroached 
upon, and there is no increase of intracranial i^ressure. Hence a re- 
tarded pulse, general headache, general i:)ercussion tenderness of the 
skull, a sensation as though the head would burst, choked disks on both 
sideSy mydriasis on both sides, nausea and vomiting, aphasic symptoms at 
first, somnolence and unconsciousness in the later stages, are all symp- 
toms to be expected in interstitial brain- abscess, while in a i^arenchyma- 
tous abscess we shall not find them, as a rule. Symptoms of brain- 
pressure may, however, be observed with the latter form of brain-abscess ; 
but these are not the result of general but of Joeal J)rain-j)ressure. The 
pus focus formed by the i)arenchymatous abscess acts like a foreign body 
on the subjacent brain-tissue. Hence we observe as symptoms of local 
pressure ocular congestion, especially when the seat of the abscess is in 
the cerebellum, mydriasis, well-marked tenderness on percussion of the 
temporal region or the occiput, and disturbances in the tracts of certain 
nerves on the side of the abscess. These localized pressure-symptoms 
are specially characteristic of the parenchymatous abscess, although they 
may to some extent appear in connection with interstitial abscesses. 

Th.e2)ulse is retarded by an increase in the general intracranial press- 
ure, while brain-pressure confined to one side affects the central territory 
of the right or the left vagus nerve, and is followed by irregularity of the 
I)ulse. Slowness of the pulse should indicate rather the presence of an 
interstitial abscess, while the irregular pulse should indicate the exist- 
ence of a parenchymatous abscess, provided there are other symptoms 
of the existence of a brain-abscess. Unilateral displacement of intra- 
cranial pressure-conditions is also induced by extradural pus-collections, 
and therefore in such diseases an irregular pulse is observed, and consti- 



216 DISEASES OF THE EAR. 

tutes a positive symptom of an extradural abscess when there is entire 
absence of symptoms of brain-abscess. 

In conclusion, it must be said that the parenchymatous abscess shows 
more central symptoms, while the interstitial abscess manifests more 
general symptoms. This is due to the fact that in the former, in addition 
to the symptoms of local pressure, there are added those due to the de- 
struction of the corresponding centres or certain conducting and connect- 
ing paths. 

The value of operation, and the prognosis, differ markedly in the two 
forms of brain-abscess. In general the prognosis as to restoration of function, 
and as to life, is more favorable in the interstitial than in the pareyichymatous 
abscess. 

Mixed Form of Abscess. — Very rarely a brain-abscess is found con- 
forming strictly in its symptoms to either one of the above descriptions : 
an abscess originally parenchymatous may produce in its neighborhood 
an interstitial abscess, or the latter form of brain-ifbscess may lead to the 
formation of a gangrenous spot in the brain substance, resulting in a 
parenchymatous abscess. Therefore, as one of these events happens in 
the majority of cases, we are usually confronted with a mixed form of 
brain-abscess, though the abscess originally very probably conformed 
strictly to either the parenchymatous or the interstitial form. 

Miiller^ also calls attention to a symptom sometimes observed in 
brain-abscess, — viz., a stiff way of holding the head, which might be 
confused with the true stiff nucha of meningitis. If a patient with a 
cerebral abscess is able to walk or move, he holds his head bent stiffly 
backward in order to prevent any increase in his headache by motion 
of his head. 

Treatment. — Abscess of the brain has been opened and drained suc- 
cessfully by way of the mastoid and middle ear, as shown by Coville and 
Lombard.^ 

In otitic abscesses of the temporal lobe the surgeon rarely finds the 
j)oint of transition of the pus from the temporal bone to the brain, 
although the position of such abscesses is directly over the tegmen tym- 
pani. In such cases the posterior and upper part of the inner wall of 
the mastoid should be removed as far as the labyrinth, the latter being 
left intact. Then a iDortion of the squama and the entire tegmen tympani 
should be removed, and the operator may penetrate as far forward as 
the tympanic mouth of the Eustachian tube and the tympanic wall of the 
cochlea. In all otitic intracranial lesions it is considered best to choose 
the way of entrance through the mastoid and middle-ear cavities, because 
exposure and inspection of these cavities may furnish excellent indica- 
tions for deeper operations. 



1 Loc. cit. * Ann. des Mai. de I' Oreille, November, 1898. 



OTITIC CEREBRAL AXD CEREBELLAR ABSCESS AND MENINGITIS. 217 
OTITIC CEREBELLAR ABSCESS. 

Prominent symptoms of otitic cerebellar abscess (perhaps for weeks) 
are intense tliough intermittent pain in tlie occiput, stiff neck, nausea 
and vomiting, subnormal temperatui^e, and varying width of the pupils, 
the wider being on the side of the abscess in the cerebellum. 

Increased knee-jerk on the side of the diseased ear and cerebellar 
abscess may be considered a characteristic symptom ; also muscular weak- 
ness, chiefly of the arm on the side of the diseased ear, and conjugate 
deviation of the eyes towards the unaffected side from weakness of 
the ocular muscles, may be considered symi3toms of the i^resence of 
a cerebellar abscess. There may also occur horizontal nystagmus and 
parah'sis of the sixth nerve on the side of the diseased ear in otitic cere- 
bellar abscess. Sometimes the intense headache in the region of the 
occiput is increased by percussion, especially over the region of the cere- 
bellar abscess. There may be also choked disk, inability to close the ej^e- 
lid, and slight facial paralysis on the affected side. The tongue will be 
protruded in some cases towards the unaffected side, and the speech may 
be sloAv and indistinct. In a sitting posture the head may fall forward, 
then turn towards the unaffected side and continue to move with pen- 
dulum-like oscillations. The vertigo is intense in such cases, being ex- 
cited by moving the head. Caries of the sigmoid groove, with thrombus of 
the sinus, or a purulent labyrinthitis, in a case of suspected brain-abscess, 
will indicate that the purulent collection is probably in the cerebellum. 

Double ojytic )i€urifls is often the only pathognomonic symptom of a 
lesion in the posterior cranial fossae. It is very likely to be i)resent in 
cerebellar tumors and otitic cerebellar abscesses, because such lesions 
readily interfere with the circulation of the cavernous sinuses and 
ophthalmic veins. Very often double optic neuritis is the only positive 
symi:)tom of otitic cerebellar abscess ; but the ej^e-grounds may remain 
normal even in fatal cerebellar abscess, as shown bj' AYoodward.^ 

JlorhkJ Groivths in the Cerebellum. — Symptoms of morbid growths in 
the cerebellum, in connection with chronic otorrhoea, may be mistaken 
for those of otitic cerebral abscess. But in these cases the slow onset and 
continuance of the symptoms — headache, vomiting, low temperature, 
choked disks on both sides — point to the probable presence of a morbid 
growth in the cerebellum rather than to an otitic abscess in that region. 

OTITIC MENINGITIS. 

Basilar meningitis may follow purulent otitis media from invasion of 
the cranial cavity through the cochlea and internal auditory meatus. 
Beach ^ calls attention to the important ftict that a chronic purulency 

1 Arch. f. OtoL, January, 1S9G. 

^ Jour, Amer. Med. Assoc. , May 6, 1896. 



218 DISEASES OF THE EAR. 

in the ear or nose may be a source of infection of the brain-cavity in 
fracture of the skull, if the latter communicate in any way with the nasal 
cavities or temporal bone and middle ear. He asserts that many cases of 
fractured cranium might recover had they not been affected with clironic 
purulent ear disease before the fracture of the skull occurred. 

Acute diffuse suppurative pachymeningitis is generally regarded 
as beyond surgical skill. Those cases of otitic meningitis reported as 
cured were evidently instances of acute circumscribed purulent pachy- 
meningitis. 

Acute Seyous Meningitis. — Acute serous meningitis is not infrequently 
caused by purulent otitis media. Boenninghaus ^ describes two forms of 
acute serous meningitis, first noted by Quincke, — viz., a malignant form, 
a meningo -encephalitis, that runs a rapid and fatal course, in which death 
occurs before the exudation can become purulent ; and a benignant form, 
in which the inflammation is limited to the pia and ventricles. The exu- 
dation remains serous. Lumbar puncture does no good in these cases. 
Puncture of the ventricles, however, is indicated. Not only does the 
latter procedure give relief, but in some cases simply opening the dura 
and the consequent brain prolai^se relieve choked ventricles. Kretsch- 
maini ^ reports a case of serous meningitis originating from cholesteatoma 
of the middle ear relieved by operation. 

AFFECTIO^^S OF THE INTERNAL EAR. 

Carious and Traumatic Lesions of the Labyrinth. — The chief symptom in 
all cases of the above-named lesions ^ is vertigo, with or without simul- 
taneous nystagmus, sixty per cent, of the cases manifesting vertigo alone, 
and twenty -two per cent, of them with it a simultaneous nystagmus. 
AYhy some cases of carious defect in the labyrinth show vertiginous symp- 
toms and others do not cannot be explained. In seventeen cases of trau- 
matic opening of the labyrinth, only once was vertigo absent. In such 
cases the vertigo is held to be due to negative pressure in the labyrinth 
induced by the escape of the labyrinth fluid and collapse of the mem- 
branous labyrinth. 

Traumatism of the Lnternal Ear. — Meniere's symptoms following trau- 
matic lesion of the labyrinth have been observed by Politzer * in a case 
of fracture of both temporal bones, involving the labyrinths. After 
death had occurred in the course of six weeks, from meningitis, a new 
growth of connective tissue in both labyrinths was detected by micro- 
scopic examination. Politzer believes that the rapid and incurable deaf- 
ness occurring in various kinds of panotitis can be explained by the de- 

^ Arch. f. Ohrenh., December 17, 1897. 

2 Miinch. Med. Woch., No. 16, 1896. 

^ Lucae, Arch. f. Ohrenh., September 29, 1899. 

* Arch. f. Ohrenh., December, 1896. 



AFFECTIONS OF THE IXTERXAL EAR. 219 

Yelopmeut of a new growth of connective tissue in the labyrinth, and 
this fact explains why even prompt and energetic absorptive treatment 
fails entirely in such cases. In some instances the deafness caused by 
violence offered to the head is supx^osed to be due to traumatic ax)oplexy 
in the labyrinth terminating in degeneration, necrosis, and secondary 
hemorrhages in the internal ear. The author believes that many cases 
of drowning from so-called sudden cramps are in reality deaths from 
incapacitating ear-vertigo from sudden entrance of cold water into the 
ear. Such an accident is all the more likely to occur if the membrana 
tympani be perforated, as the cold water easily impresses the internal 
ear. It is worthy of note that in cases of drowning from so-called 
'^cramps'' the victim is generally seen to throw up his arms in his 
struggles ; he cannot, therefore, be cramped in his arms or trunk. It 
has always seemed to the author that these struggles of the drowning 
man were due to his effort to regain his bearings, which had been lost 
hj the disturbed equilibrium induced by irritation of the labyrinth from 
the sudden entrance of cold water into the ear. 

Internal Ear in Submarine Laborers. — Apoi^lectiform affections of the 
labyrinth are said to occur in men emi^loyed in submarine caissons. 
When the Eustachian tube is permeable, the ear endures the increased 
atmosiDheric i^ressure in submarine caissons, but when this tube is not 
permeable, the inward pressure of the membrana, finding no recoil of 
air through the Eustachian tube, i)roduces congestion of the drum-cavity 
and finally of the internal ear (F. Alt). 

Si/2)^iilis of the Infernal Uar.—X form of acute sj'philitic affection of 
the ear, probably due to an effusion into the labyrinth in a previously 
normal ear, churacterized by sudden deafness, tinnitus, and vertigo, 
coming on in the late secondary or early tertiary stage of systemic syi)hilis, 
is described by E. A. Crockett.^ The difference between this form of 
sudden deafness, tinnitus, and vertigo and that due to non-syphilitic 
causes is that the deafness is not so profound in the specific form. This 
syphilitic aural affection yields prom^^tly to a few doses of i^ilocarpine 
(one-sixth grain) given hypodermically, whereas non-syphilitic labyrinth 
diseases are entirely unaffected by pilocari^ine. In fact, pilocarpine gives 
the best results in syphilitic diseases of the internal ear. 

Tuberculous disease of the temporal bone may terminate in extensive 
destruction of the mastoid, the lower i^art of the squama, the petrous 
pyramid, and partial thrombosis of the sux:)erior petrosal and sigmoid 
sinuses, with tuberculous disease of the sphenoid and occipital bones 
(Barnick) . 

Internal Ear in Leulccemia. — In leukaemia the internal ear is often af- 
fected by profound and sudden deafness, sometimes accompanied by 
so-called Meniere's symptoms. 

^ Boston Med. and Surg. Jour., February 11, 1897. 



220 DISEASES OF THE EAR. 

Internal Ear in BipJitheria. — Sudden ambilateral total deafness in true 
faucial diphtheria^ in a woman of thirty-three^ with previous good hear- 
ing and no history of syphilis, has been reported by J. C. Wilson/ The 
middle ears seemed in no way affected. The tinnitus and vertigo were 
marked at first, but gradually, in six months, the tinnitus greatly dimin- 
ished and the vertigo ceased. Large doses of pilocarpine, with marked 
constitutional impression, were given in this case. The deafness remained 
great and unchanged. As in this case there was a profound chemosis of 
the eyes at the outset, it is reasonable to supi^ose that there was a similar 
engorgement of the lymphatics of the internal ears. This serous effusion 
into the labyrinth was sufficient to squeeze the nerve-tissues so forcibly 
as to entirely and permanently destroy the function of hearing, just as it 
apparently does in syphilis and mumps. 

Ancemia of the LahyriRth. — Deafness, tinnitus, and vertigo may be 
caused by either congestion or an&emia of the labyrinth, as shown by 
Lermoyez. ^ The inhalation of a few droits of amyl nitrite, as he shows, 
will temporarily relieve these symptoms if they be due to ischsemia, but 
will increase them if they be due to congestion. In a case of anaemia of 
the labyrinth, Lermoyez found that trinitrin (too grain) three times daily 
permanently relieved the deafness, tinnitus, and vertigo. This treatment 
I have aiDplied with success in similar cases. In cases of congestion of 
the labyrinth an alterative or absorbent treatment is indicated. 

Tinnitus Aurium. — Tinnitus aurium in neurotic cases without ear dis- 
ease is purely cerebral. In all cases of tinnitus coming before the neu- 
rologist the ear should be examined in order to find out whether or not 
organic ear disease is present. Tinnitus when a warning of epileptic fits 
must be regarded as originating in the auditory centre in the cortex and 
not in the auditory nerve (W. E. Gowers). 

Fsychic Deafness. — Psychic deafness is often confounded with deaf- 
muteness. The former is an inability to learn to talk in one who can 
hear rather than muteness in one who cannot hear and has therefore 
never learned to talk. In cases of psychic deafness in the young, by com- 
bating nervous excitability and awakening and cultivating the faculty of 
concentration and perception, the power of speech may be gained (Hel- 
ler). Psychic dulness of hearing may develop in the adult with neurotic 
tendencies. Under careful acoustic exercises by words spoken slowly 
and near the ear, fair hearing may be regained. Many cases of psychic 
deafness seem to possess what some observers call '4atent hearing." 

Hallucinations of Hearhig. — The ears in the insane affected with hal- 
lucinations of hearing will generally show organic changes competent to 
produce subjective noises in the ear. Misinterpretation of these sounds 
in the ears causes hallucinations. 



^ Congress of American Physicians and Surgeons, May, 1897. 
2 Ann. des Mai. de 1' Oreille, July, 1896. 



DISEASES OF THE NOSE AND 
NASOPHARYNX. 

BY E. FLETCHER INGALS, A.M., M.D., 

Professor of Diseases of the Chest, Throat, and Xose, Eush Medical College 

of Chicago. 

ASSISTED BY 

OTTO T. FREER, M.D., 

Instructor in Diseases of the Chest, Throat, and Xose, Rush Medical College 

of Chicago. 



CHAPTEE I. 

ANATOMY AXD PHYSIOLOGY OF THE XOSE AND XASOPHARYXX. 
AXATOMY AXD PHYSIOLOGY OF THE XOSE, 

The description of the aiiatomj' of the nose includes that of the ex- 
ternal or facial nose, the internal nasal i^assages, or nasal fossjie, and the 
bon}^ air-cavities adjoining these, called the accessory sinuses. 

The External ]sose. — In considering the outward appearance of this, 
one sx)eaks of the root of the nose, radix nasi, which is the part lying 
between the inner canthi of the lids ; the alee nasi, which are the movable 
wing-like portions bounding the nostrils externally ; the apex nasi, or tip 
of the nose; the dorsum nasi, or back of the nose, extending from the 
tip to the root ; and the sella nasi, or saddle of the nose, which is the 
depression where the back of the nose joins the forehead. The alee nasi, 
or wings of the nose, are bounded above by a furrow called the sulcus 
alaris, below by the opening of the nostril, and posteriorly by the groove 
between the nose and cheek, called the sulcus nasolabialis. The internal 
boundary of the nostrils is formed by the i^onticulus nasi, which forms 
the lower border of the nasal septum's unattached portion. 

Skeleton of the External Xose. — This consists of the nasal bones, the 
nasal processes of the superior maxillae, and the premaxillary portion of 
the upper j aw, the so-called pars incisiva. The nasal bones form the bridge 
of the nose. They articulate above with the nasal process of the frontal 
bone ; their outer borders join the nasal processes of the upper jaw. At 
their inner margins the nasal bones join to form a median crest for junction 

221 



222 



DISEASES OF THE NOSE AND NASOPHARYNX. 



Fig. 87. 




with the nasal spine of the frontal bone above, below this with the vertical 
plate of the ethmoid bone and the septal cartilage. The posterior surface 
of the nasal bones presents a longitudinal groove for the nasal nerve. The 
external surface of the nasal process of the superior maxilla is smooth 5 
its inner surface presents two crests for the attachment of the middle and 
inferior turbinated bones (crista conchalis superior et inferior). Above, 
the inner surface joins the ethmoid bone, closing a part of the anterior 
ethmoidal cells. The upi^er border of the nasal process of the upjper jaw 
articulates with the frontal, tlie anterior border with the nasal bone. 
Posteriorly it articulates with the lachrymal bone in the lachrymal 
groove. Below their junction with the nasal bones the nasal processes 
of the superior maxillae present a smooth, unattached margin which 

extends concavely downward to the alve- 
olar process. 

The pars i^rsemaxillaris of each upper 
jaw unite in the centre to form the in- 
cisor, also called superior maxillary crest, 
for the reception of the septal cartilage, 
the crest ending in front in the inferior 
nasal spine. The nasal bones, nasal pro- 
cesses of the suj)erior maxillae, and the 
pars incisiva unite to form the pear- 
shajDcd opening of the nasal passages 
called the apertura pyriformis. 

The cartilages of the external nose 
cover the apertura pyriformis in the form 
of a projecting roof. From above down- 
ward the cartilaginous portion of the 
external nose is formed by the anterior 
projecting border of the cartilaginous 
septum, the triangular or upper lateral 
cartilages, the small minor or quadrate 
cartilages, and the alar or lower lateral 
cartilages. The ux:>per lateral or triangu- 
lar cartilages are two flange-like extensions of the cartilaginous septum. 
In the centre, in their upper x^ortions, they are continuous with the sep- 
tum, but below this are divided from it by a fissure. The triangular car- 
tilages pass beneath the edges of the nasal bones and nasal processes of 
the superior maxillae for the distance of a few millimetres, articulating 
with them. Their lower borders are covered by portions of the alar car- 
tilages, so that the margins of the triangular cartilages are covered as 
seen from without, except at their central junction. The lower borders 
of the triangular cartilages project into the nose, dividing its vestibule 
into an upper and a lower portion. The lower lateral or alar cartilages 
bound the greater portion of the nostrils anteriorly. Each cartilage has 




%v ^- 



Framework of the external nose. 
(Zuckerkandl.) F, nasal process of fron- 
tal bone ; n, nasal bone ; s, s, ascending 
branch of superior maxillary bone ; t, 
triangular cartilage ; a, a', lateral limb of 
alar cartilage ; i, inner limb of alar car- 
tilage : between a and t, sesamoid carti- 



AXATOMY AND PHYSIOLOGY OF THE NOSE AND NASOPHARYNX. 223 

two plates, the outer oue of which lies along the outer border of the 
nostril, while the inner one meets its fellow in the centre and passes back- 
ward along the inner border of the nostril. Both x^lates unite in front at 
an acute angle 5 neither extends backward along the entire length of the 
nostril, but stops about one-half way back, so that the remaining space 
is filled in with fibrous tissue. Thus the ala of the nose is made uj) of 
this and skin only. The minor alar cartilages are small cartilaginous 
plates behind the alar cartilages, lying as continuations of these in the 
fibrous tissue. 

The muscles of the external nose are the i)yramidalis nasi^ compressor 
naris, levator labii su^^erioris ahieque nasi, and depressor al?e nasi. The 
pyramidalis nasi arises from the lower border of the nasal bone and is 
inserted into the skin between the brows ; it draws the skin downward. 
The compressor uaris arises from the nasal bones and cartilages and, pass- 
ing downward and backward, is inserted into the superior maxillary 
bone near the apertura pyriformis ; it wrinkles the nose verticalh'. The 
levator labii superioris alieque nasi arises from the nasal process of the 
superior maxilla and, passing downward and outward, is inserted into 
the wing of the nose and the upper lip ; it lifts the wing of the nose. The 
depressor alae nasi arises from the incisor fossa of the u^Dper jaw and is 
inserted into the wing of the nose and the septum ; it draws the ala of 
the nose downward and inward. 

The facial artery sends the ramus alaris inferior et superior to the 
wings of the nose and a large branch to its dorsum, the arteria dorsalis 
nasi. The nasal artery, a branch of the oijhthalmic, leaves the orbit in 
the region of the inner canthus and anastomoses with the branches of the 
facial 5 it supplies tlie root and sides of the nose. The veins of the 
nose — vente dorsales et laterales nasi — emj^ty into the angular vein. The 
lymph-channels connect with the submaxillarj' lymph-glands. 

The nasal muscles are supplied by the buccal branches of the facial 
nerve. The back of the nose receives sensation from the first division of 
the fifth nerve through the nasal and infratrochlear nerves. The lateral 
portions of the nose are supplied by the second division of the fifth, 
cranial nerve through the lateral nasal brandies of the infraorbital nerve. 
The vestibule of the nose is that portion of the nasal passages placed in 
front of the nasal fosScT proper, and is bounded externally by the wings 
of the nose. The vestibule of the nose extends as high as the limen nasi, 
a x^rominent ridge caused by the lower border of the superior lateral or 
trians^ular cartilaoe. 

The space occupied by the nasal passages in the skull is called the 
cavum nasi, divided by the nasal septum into two i^assages, the nasal fosste. 
These begin in front at the vestibulum nasi and extend back to the 
choaniB or posterior nostrils. Above, they reach to the anterior fossa 
of the skull ; below, to the hard palate ; laterally, they are bounded by 
the ethmoid cells and upper jaw. The floor is almost horizontal, the 



224 



DISEASES OF THE NOSE AND NASOPHARYNX. 



septum, or dividing wall, vertical, and the roof is concave antero-pos- 
teriorly. The nasal part of this extends downward and forward, the 
ethmoidal portion horizontally, the sphenoidal part descends at first ver- 
tically and then extends almost horizontally backward. The jutting 
angle thus formed is called the promontorium sphenoidale. 

The nasal septum is made up of the vomer, the vertical plate of the 
ethmoid bone, and the cartilage of the septum. The vomer is quadri- 
lateral in form, and its lower border articulates with the nasal crest of 

Fig. 88. 




1.-) 14 

View of the nasal septum, x %. (Heymann, after Mihalkovics.) 1, crista galli ; 2, cribriform 
lamina; 3, perpendicular lamina; 4, sphenoid; 5, sphenoid process; 6, sphenoid sinus; 7, vomer; 8, 
sphenoid ; 9, clivus ; 10, pharyngeal fornix ; 11, nasopharynx ; 12, Eustachian tube ; 13, pharynx ; 14, 
soft palate ; 15, uvula ; 16, hard palate ; 17, maxillary bone ; 18, membranous septum nasi ; 19, apex 
nasi ; 20, septal cartilage ; 21, nasal bone ; 22, frontal sinus. 



the superior maxillae and j)alate bones. The anterior angle fits in behind 
the incisor crest of the superior maxillse, and the superior border is 
attached to the rostrum of the sphenoid bone by two wing- like pro- 
jections, or alse. The oblique anterior border joins the vertical 
plate of the ethmoid bone above, below it is grooved for the passage of 
the nasopalatine nerve on its way to the anterior palatine canal. The 
vertical plate of the ethmoid bone (lamina perpendicularis) is pentagonal 5 
its upper border — the longest— joins the cribriform plate, its anterior 



ANATOMY AXD PHYSIOLOGY OF THE XOSE AXD NASOPHARYXX. 225 

sliort border articulates with the nasal spine of the frontal bone and the 
median crests of the nasal bones, and the posterior border with the crest 
of the sphenoid. The lower anterior border is joined to the septal 
cartilage, while the lower posterior border joins the vomer. 

The cartilage of the septum is irregularly quadrilateral. Its shortest 
lower border extends unattached in the movable part of the sei)tum, 
and lies above and behind the central plates of the alar cartilages of the 
external nose. The lower border of the sei^tal cartilage joins the an- 
terior border by a rounded angle. The anterior border is inseparable 
from the superior lateral cartilages of the external nose, extending to 
the crest of the nasal bones above. The upper and posterior borders of 
the cartilaginous sei^tum meet at an acute angle, formed by the vomer 
and perpendicular plate of the ethmoid bone, to which bones they are 
attached. The septal cartilage is usually thinnest in the vestibule of the 
nose and gets thicker back of this. It is formed of two plates, one for 
each nasal fossa, which are applied to each other for the entire extent of 
their inner surfaces. The septum is entirely covered by the nasal mucous 
membrane, the histology of which will be considered in another part of 
this article. In the region of the anterior j)iihitine canal (canalis naso- 
palatinus) a short epithelial canal is found in the septal mucous mem- 
brane. This is called the organ of Jacobson, the entrance to which is 
not more than one millimetre in diameter. It is a rudimentary repre- 
sentation of an organ of the sense of smell found in some lower animals. 

The arterial and nervous supply of the septum nasi is double, — that 
is, each artery and nerve has its mate on the other side of the septum, 
due to embryological development. The anterior i:)art of the septum 
receives branches from the arteries of the external nose and the anterior 
ethmoidal artery, a branch of the oi^hthalmic. The posterior part of the 
sex)tuni is supi^lied by the sphenopalatine artery, a branch of the internal 
maxillary, which reaches the septum after passing through the spheno- 
palatine foramen. The arter}' then passes downward and forward on the 
septum to the anterior palatine canal. 

The veins of the septum empty into the vena sphenopalatina and the 
ethmoidal veins. They also communicate freeh' with the veins of the 
dura by passing through the foramina of the cribriform x)late of the eth- 
moid bone. This is a fact of importance in regard to emboli or thrombi 
due to disease of the septum. A part of the sei)tum above the pars 
incisiva of the upper jaw, of an area the size of a cent, is supplied 
with papilla with large central veins and covered by a thin layer of 
pavement epithelium. This place is known as the seat of frequent bleed- 
ings from the nose, owing to its peculiar vascular supply. 

The sensory nerves of the se^^tum come from the first and second 
divisions of the fifth pair. The anterior part of the septum, as far back 
as the pars incisiva of the upper jaw extends, is supplied by the septal 
branch of the nasal nerve. The latter, after enterino; the nose through 

15 



226 DISEASES OF THE NOSE AND NASOPHARYNX. 

the foremost foramen of tlie cribriform plate, passes under the mucous 
membrane in a groove under the nasal bones and becomes cutaneous on 
the back of the nose. The rest of the septum is supplied by the naso- 
palatine nerve, a branch of the second division of the fifth pair. The 
nasopalatine nerve enters the nasal cavity through the sphenopalatine for- 
amen, and passing obliquely downward and forward on the septum, ]3asses 
through the anterior palatine canal (canalis nasoiDalatinus) to the roof of 
the mouth. It is owing to the course of this nerve on the septum that 
operations for the removal of spurs or necrotic pieces of bone from the 
vomer cause pain referred to the upper incisor teeth. 

The branches of the olfactory nerve do not reach below the upper 
third or fourth of the septum, and are spread out in a coarse net- work 
of branches. These pierce the foramina of the cribriform plate of the 
ethmoid bone, and are accompanied by a sheath of the dura mater. 

The roof of the cavum nasi presents a nasofrontal, ethmoidal, and 
sphenoidal portion. The nasofrontal portion is the part lying under the 
nasal bones. The ethmoidal portion is covered by the cribriform plate 
of the ethmoid bone, with its two rows of foramina for the passage of 
the inner and outer bundles of olfactory nerve-fibres. The most anterior 
of these foramina gives x)assage to the nasal nerve. The sphenoidal por- 
tion of the nasal roof includes the body of the sphenoid bone. The 
anterior vertical surface of this joins the ethmoid bone at right angles 
from below and forms a recess called the recessus spheno-ethmoidalis. 
The openings of the sphenoidal sinuses are to be seen on this anterior 
vertical surface of the body of the sphenoid bone. They are quite large 
in the skeleton, but when covered with mucous membrane vary from the 
size of a pin-head to that of a lentil. As a rule, the opening to the 
sphenoidal sinuses lies just beneath the cribriform plate of the ethmoid 
bone, more rarely in the centre below this. 

The floor of the nasal cavity is formed by the pars incisiva of the 
superior maxillae, their jDalatine i^rocess, and the horizontal plate of the 
palate bone. About one-half to three-quarters of an inch behind the 
inferior nasal sxDine the canalis nasopalatinus, or anterior palatine fora- 
men, is located. The foramina from the two sides converge and open by 
a single opening into the mouth behind the incisor teeth. This canal is 
closed by the soft ]3arts. The lateral wall of the nasal cavities is formed 
by the ethmoid bone, the inferior turbinated bone, the upper jaw, the 
vertical plate of the palate bone, and the internal pterygoid plate of the 
sphenoid bone. The lateral mass of the ethmoid bone contains the 
ethmoid cells or labyrinth, and extends from the roof of the nose down 
to the level of the floor of the orbit. Posteriorly the lateral mass articu- 
lates with the rough surface on each side of the body of the sphenoid 
bone. Anteriorly it articulates with the lachrymal bone and the nasal 
process of the sux^erior maxillary bone, above with the orbital portion 
of the frontal bone on each side of the ethmoidal notch, the frontal bone 



AXATOMY AXD PHYSIOLOGY OF THE NOSE AND NASOPHARYNX. 



227 



presenting depressions which, when joined to corresponding ones in the 
ethmoid bone^ comiDlete some of the ethmoidal cells and the anterior and 
posterior ethmoidal canals. Below, the lateral mass of the ethmoid bone 
articulates with the orbital portion of the upper jaw and orbital process 
of the palate bone. All these neighboring bones help to close in the 
ethmoidal cells, some even containing accessory air-cells. On the outer 
surface the lateral mass of the ethmoid bone is closed by the thin lamina 
j)apyracea, or orbital i^late, which forms part of the inner wall of the 
orbit. This is apt to be forced in towards the orbit in disease of the eth- 



FiG. 89. 




Lateral wall of the nose ; sounds lying in the laclirymonasal duct and in the cavity of the sphenoid. 
X%. (Heymann, after Mihalkovics.) 1, crista galli; 2, cribriform lamina; 3, middle turbinate; 
4, superior turbinate ; 5, spheno-ethmoid recess ; G, superior (turbinate) meatus ; 7, opening of sphenoid 
sinus; S, sphenoid sinus; 9, sphenoid prominence; 10, sphenoid bone; 11, nasopharyngeal meatus; 
12, pharyngeal recess ; 13, mouth of Eustachian tube ; 14, salpingopalatine fold ; 15, soft palate ; 16, hard 
palate ; 17, nasolachrymal duct ; IS, inferior turbinate ; 19, ala nasi ; 20, entrance to middle meatus ; 
21, apex nasi; 22, limen nasi; 23, agger nasi; 24, dorsum nasi; 2."), nasal bone; 26, root of the nose; 
27, fornix nasi ; 28, frontal sinus. 

moid cells, causing displacement of the globe. The inner or mesial wall 
of the lateral mass forms the outer wall of the nasal fossa, and is com- 
posed of two shell-like bones, the upper and middle turbinates. These 
are grooved for the fibres of the olfactory nerve and for blood-vessels. 

The inferior turbinated bone divides the middle from the inferior 
meatus of the nasal fossa. At its upper margin it is attached to the 
inferior turbinate crest of the superior maxilla in fi-ont, beliind this by 
means of the lachrymal process to the lachrymal bone, back of this the 
maxillary process descends to close the lower part of the opening to the 
antrum. Posteriorly the inferior turbinated bone articulates with the 



228 DISEASES OF THE NOSE AND NASOPHARYNX. 

uncinate process of tlie ethmoid by means of the ethmoidal process. 
The body of the inferior turbinated bone curls outward and downward 
over the inferior meatus of the nose. The nasal surface of the body of 
the superior maxilla forms the greater j)art of the outer wall of the nasal 
fossa, but is covered almost entirely by the two lower turbinated bones. 
In front it presents a crest for articulation with the lower turbinated 
bonCj above and behind this is the large opening to the antrum of High- 
more, the closure of which is completed by the inferior turbinated bone, 
the palate bone, and the uncinate process of the ethmoid. Above this 
the nasal surface of the body of the upper jaw presents one or two half- 
cells closed by junction with the ethmoid bone. Behind it articulates 
with the palate bone. This presents two crests (cristse conchales) for 
junction with the two lower turbinated bones. 

The arteries supplying the mucous membrane of the nose, except the 
septum (considered above), are the outer branch of the sphenopalatine 
arterj^, which anastomoses with the branches of the anterior ethmoidal 
artery from the ophthalmic and the branches of the facial to the septum. 

The veins form a close net- work in the mucous membrane, and over the 
turbinates produce a species of cavernous plexus, which accounts for the 
tendency of the mucous surface of the turbinated bodies to swell rapidly. 
The lymph- channels discharge towards the palate and x^harynx and empty 
into the cervical glands. The lymph- vessels connect by means of the 
cribriform plate with the subdural and subarachnoid spaces. The an- 
terior part of the mucous surface of the nose is supplied with sensation 
by the nasal nerve over a region corresponding to its cutaneous distri- 
bution from the root of the nose to its tip. The greater part of the 
mucous membrane of the nose receives sensation from the superior and 
inferior nasal branches derived from Meeker s ganglion, second division 
of the fifth pair of cranial nerves. The superior branches are distributed 
to the mucous membrane over the upper and back part of the septum 
and over the superior and middle turbinated bodies. The inferior 
branches are distributed to the inferior turbinated bodies and correspond- 
ing part of the lateral wall of the nose. The anterior superior dental 
nerve gives off a branch in the wall of the antrum, which supplies the 
mucous membrane of the anterior part of the inferior meatus and floor 
of the nasal fossa. The lateral portion of the fibres of the olfactory 
nerve is spread over the upper surface of the middle turbinated body as 
far down as the lower border of the superior turbinate. The turbinated 
bodies do not extend along the whole length of the lateral wall of the 
nasal fossa. The lower reaches farthest forward, the middle nearly as 
far, while the superior is not visible from in front and extends as far for- 
ward as the posterior third of the middle turbinal only. In front of the 
anterior ends of the turbinated bodies is a smooth triangular surface 
called the atrium meatus medii. The only point of interest here is the 
agger nasi, a low elevation continuous with the middle turbinate. 



ANATOMY AXD PHYSIOLOGY OF THE XOSE AND NASOPHARYNX. 229 

The middle turbinated body is much larger than the upper, — from 
oue and one-quarter to one and one-half inches long and five-eighths of an 
inch high. Its attachment is i^eculiar in that anteriorly it has the shape 
of an inverted U, creating a deep recess (recessus frontalis, Killian). 
This recess is not visible until the middle turbinal is removed. Its top 
reaches up nearly to the floor of the frontal sinus, underneath the middle 
turbinal. The inferior turbinal is less deep than the middle, but longer, 
— from one and one-half to two inches. It curves downward usually to 
within one-eighth of an inch of the nasal floor. The turbinated bodies 
are often rudimentary in their develoi)ment, a condition causing abnor- 
mally large passages, with a tendency to drying and decomposition of 
secretions. 

Fig. 90. 




Transverse section through the posterior portion of the nasal cavity. (Zuckerkaudl.) U, lower 
turbinal ; M. middle turbinal; 0, superior turbinal; S, septum; P, hard palate; IT, antrurc of High- 
more ; E. ethmoidal cells ; ,1, orbit; fo, olfactory region ; rr, respiratory region. 



There are three nasal meatuses. The upx^er is short, lies under the 
superior turbinal. and extends forward only as far as the middle of the 
cribriform i)late of the ethmoid bone. It contains the openings of the 
posterior ethmoidal cells. 

The middle meatus consists of a portion underneath the middle tur- 
binated body and a part hot covered by this. This latter portion is 
wider in front than behind, begins at the atrium meatus nasi medii, or 
vestibule of the middle meatus, in front, and extends back to the anterior 
fold of the Eustachian opening. The portion of the middle meatus 
covered by the middle turbinated body is a region of great importance to 
the rhinologist. It is narrow behind and wider in front, where it forms 
the recessus meatus medii mentioned above. 

The outer wall of the middle meatus x)resents a semilunar sulcus of 



230 



DISEASES OF THE NOSE AND NASOPHARYNX. 



curved shape, with its concavity upward, its anterior end extending into 
the recessus. This is the infundibulum, also called the hiatus semilunaris. 
The infundibulum may be shallow or a deep narrow slit. From before 
backward the frontal sinus, anterior ethmoidal cells, and maxillary sinus 
empty into it. The opening of the frontal sinus is in the highest upper 
part, and may be of the size of a lentil. The opening of the antrum lies 
in the posterior shallow part of the hiatus semilunaris, and is usually 
surrounded by a fold of mucous membrane. The size of the opening 
varies, and is from one-quarter to three-eighths of an inch in diameter. 
The opening in the skeleton is much larger than the opening in the 




Lateral wall of the nose ; the middle and inferior turbinate are removed. (M. Schmidt, after 
Merkel.) 1, frontal sinus; 2, ethmoidal bulla; 3, maxillary sinus; 4. ethmoidal cell; 5, sphenoidal 
sinus ; G, pharyngeal recess ; 7, Eustachian tube ; 8, nasolachrymal canal ; 9, limen nasi ; 10, agger 
nasi ; 11, lateral ridge of mucous membrane. 



mucous membrane. Just above the hiatus semilunaris there is a promi- 
nence due to a large ethmoidal cell. This is called the bulla ethmoidalis. 
The inferior meatus has a narrow uncovered portion, which begins in 
front over the pars incisiva of the upper jaw and is lost behind in the 
salpingopalatine fold of the Eustachian orifice. A little in front of the 
centre of the portion covered by the inferior turbinated body is the 
opening of the lachrymal duct. This opening may lie immediately 
under the insertion of the lower turbinated body or be found lower down 
near the centre of the meatus. 



ANATOMY AND PHYSIOLOGY OF THE NOSE AND NASOPHARYNX. 231 

The accessory sinuses of the nose are air-chambers surrounding the 
nasal cavity on all sides. The frontal sinuses are situated in the frontal 
bone above the root of the nose, and extend laterally to about the region 
of the supraorbital notch. They are separated by a thin, bony septum 
that is seldom in the middle between the two sinuses, but usually a little 
to one side of this. The frontal sinuses vary greatly in extent. They 
may be rudimentary or absent, and are smaller in women and children 
than in men. If large, they may extend backward the entire length of 
the orbit and laterally as far as the zygomatic j)rocess. The opening 
of the frontal sinus is at its lowest i>ortion, and usually ox:)ens directly 
into the upper i^art of the infundibulum without a canal or duct inter- 



FiG. 92. 




Horizontal section of the face through the ethmoid region. X %■ (Heymann and ron Mihal- 
kovics.) 1, external nose; 2, opening of the nostril ; 3, frontal process; 4, anterior ethmoid cells; 
5, septum ; 6, olfactory fissure; 7, lamina papyracea ; S, posterior ethmoid cells; 9, sphenoid sinus; 
10, sphenoid hone. 



vening, unless one is provided by encroacliment of ethmoidal cells. The 
nerves of the frontal sinus are branches of the nasal nerve. 

The ethmoidal cells fill in the space between the orbit and lateral wall 
of the nasal fossa. Thej' are divided by a transverse septum into an an- 
terior and posterior set of cells. The anterior cells emj)ty into the infun- 
dibulum in its middle portion, the posterior into the upper meatus. The 
ethmoidal cells are separated from one another by thin plates of bone. 

The anterior ethmoidal cells are supj^lied with sensation by the nasal 
nerve a^ it passes through the anterioi' ethmoidal foramen. The posterior 
ethmoidal cells are supplied by the posterior ethmoidal nerve. The arte- 
rial supply is derived from the anterior and posterior ethmoidal arteries, 
branches of the ophthalmic. 



232 



DISEASES OF THE NOSE AND NASOPHARYNX. 



Like the frontal, the sphenoidal sinus varies greatly in size, from a 
rudimentary^ state to one in which it sends prolongations into the 
pterygoid processes and greater and lesser wings of the sphenoid bone. 
The sphenoidal sinus is divided into two lateral portions by a septum. 
This septum is seldom central, so that the two divisions of the sinus are 
of unequal size. They have an irregularly triangular shape, broadest in 
front. The opening of the sphenoidal sinus is high up under the nasal 
roof in the recessus spheno-ethmoidalis ; it is small and poorly located for 

Fig. 93. 




The outer wall of the nasal fossa removed and the lachrymal duct opened its entire length. 
(Stoerk.) pd, hard palate ; vii, lower meatus ; ci, lower turbinal ; mm, middle meatus ; cm, middle tur- 
hinal ; ms, superior meatus ; cs, upper turbinal ; dl, ductus lachrymalis ; sf, frontal sinus ; ce, anterior 
ethmoidal cells ; ce', posterior ethmoidal cells ; s, septum ; ^8, sphenoidal sinus. 



drainage. The nerves of the sphenoidal sinus are derived from the Vidian 
nerve. 

The antrum of Highmore, or maxillary sinus, is the most important 
of the accessory sinuses. It presents four surfaces, — orbital, facial, nasal, 
and temporal. The orbital or upper surface is formed by the thin plate 
of bone which is the floor of the orbit. The facial surface has the thickest 
and strongest wall. It is heavily buttressed by a ridge leading from the 
first molar tooth to the zygomatic process, which divides the temporal 
from the orbital surface. The facial wall is thinnest in the canine fossa, 
but not very thin here. The temporal surface faces downward and back- 
ward. It is formed by a thin plate of bone separated from the great wing 
of the sphenoid by the inferior orbital or sphenomaxillary fissure. Its 



ANATOMY AXD PHYSIOLOGY OF THE XOSE AND NASOPHARYNX. 233 

surface is convex and on the same i)lane as that of the temporal surface 
of the great wing of the sphenoid bone. The nasal surface is vertical and 
chiefly situated under the lower turbinated bone in the lower meatus. 
The antrum has no floor i^roper, as its surfaces converge towards the 
bottom, which, is formed by a trough or groove above the alveolar process 
of the roots of^he teeth, called the sulcus alveolaris. In men this usually 
is on a level with the floor of the nose, in women on a lower level. The 
opening of the maxillary sinus, as seen from within, is placed high up 
under the orbital plate, and connects with the infundibulum by a short 
oblique duct. This explains the difficulty of probing the natural opening 
to the sinus and its unfitness to act as a drain in cases of empyema. The 
posterior su^^erior, the middle superior, and the anterior superior dental 
nerves are contained in the walls of the antrum. They are separated from 
its mucous membrane by a laj'er of thin bone forming the inner wall of 
the canals in which they are contained as they pass down to the teeth of 
the upper jaw. This thin plate of bone may atrophy, so that these nerves 
often run directly underneath the mucous membrane of the antrum, 
causing severe neuralgias in case of disease of this sinus. The infra- 
orbital nerve is also verj^ near the mucous surface, so that it can be seen 
from below. The arteries of the antrum come from the infraorbital 
artery and the lateral arteries of the nasal cavity. The superior dental 
nerves just mentioned supi)ly the mucous membrane of the antrum with, 
sensation. 

The interior surface of the antrum may present partial septa, causing 
deep pockets, or complete septa, dividing the sj^ace into two or more 
cavities. In this latter case, in operations for empyema of the antrum, 
the operator may open a cavity containing air while he fails to reach, 
the one containing pus. The floor of the antrum may be so low that the 
alveoli of the teeth iDroject into it as prominences, or that the roots of 
the teeth may be seen covered only by mucous membrane, the bone being 
deficient. As a result of deficient absorption of the spongy tissue of 
the upi^er jaw, the antrum may be very small and have thick walls, so 
that the surgeon unay find it hard to penetrate them. The walls of the 
antrum may so api^roximate that it becomes a mere fissure rather than a 
cavity. Such cases present facial asymmetry with a sunken cheek and 
enlarged nasal fossa on the affected side. The antrum may be abnormallj' 
large and present extensions into the malar bone or hard palate. 

The Mucous Membrane of the Xose. — The integument with hairs and 
sebaceous glands enters the nostrils from the face and extends inward as 
high as the alar cartilages reach. Where the alar cartilages join the 
superior lateral cartilages, the so-called limen nasi, there is a narrow zone 
in which the integument i^resents the characteristics of mucous mem- 
brane with pavement epithelium and muciparous glands. This pavement 
epithelium gradually merges into the typical ciliated epithelium of the 
lining of the nasal passages, called the respiratory mucous membrane. 



234 



DISEASES OF THE NOSE AND NASOPHARYNX. 



Fjg. 94. 



^ 



@ m ^' 



% 



The ciliated epithelial liniiig of the floor and outer wall of the nasal passages 
reaches forward towards the nostrils about as far as the lower anterior 
border of the superior lateral cartilage. The anterior j)ortion of the in- 
ferior turbinated body may have pavement or ciliated epithelium. On 
the septum the same conditions exist. First a region with skin with hair- 
follicles extending upward as far as the alar cartilage reaches, then a zone 
of mucous membrane with i)avement ei:)ithelium which reaches back from 
the dorsum nasi as far as the thin anterior part of the septum extends. 
Here the pavement epithelium also gradually merges into the ciliated 
variety. Where the lining membrane of the nose is of the character of 

the skin the subepithelial 
connective tissue is dis- 
tinct from the perichon- 
drium, to which it is but 
loosely connected. Above 
the alar cartilages, how- 
ever, where the mucous 
membrane proper begins, 
the periosteum or peri- 
chondrium is firmly united 
to the submucous connec- 
tive tissue. Where pave- 
ment epithelium merges 
into ciliated the pavement 
epithelium extends for a 
short distance under the 
cilated variety. As the 
ciliated epithelium is ap- 
proached the pavement 
cells get rounder, then 
conical ; finally, short cili- 
ated epithelial cells ap- 
pear with goblet-cells un- 
til the typical long ciliated 
ei)ithelium is reached. 
Papillae with loops of blood-vessels extend from the nostrils inward only 
as far as the respiratory mucous membrane with ciliated epithelium. 
This variety of epithelium covers all but the cutaneous portions of the 
nasal lining at the nasal entrance just mentioned and the mucous mem- 
brane of the olfactory region. The mucous membrane of the nose is thin 
in the accessory sinuses, thickest over the turbinals, where it may be 
from one-eighth to one-quarter of an inch thick. It is inseparable from 
the periosteum or perichondrium. The posterior ends of the turbinated 
bodies are apt to present wrinkles and papillary elevations. These are 
liable to hypertrophy in chronic hypertrophic rhinitis. 






<©■ 



i 






% 



Section through normal mucous membrane of the middle 
turbinal, showing epithelium and connective tissue beneath. 
(Sehiefferdecker.) The long bright spaces between the ciliated 
cells are the portions of the goblet-cells which are filled with 
mucus. The light streaks which traverse the basement mem- 
brane are the basal canals. The dark enclosed bodies are the 
nuclei of leucocytes, which can be seen in the epithelium as 
well as beneath it. 



PLATE VII. 

A section through the mucosa and bone on the inner surface of the lower turbinal. 
To the left the divided lumina of empty mucous glands are visible ; to the right 
mucous glands with efferent duct. This and the glands are filled with secretion. 
The epithelium on the surface shows the cilia. In the upper portion of the mucosa 
the ascending branches of arteries can be seen ; in the deeper portions the muscular 
and connective-tissue walls of the lacunar veins are apparent. The elastic fibres can 
be observed to take an ascending direction from the periosteum. The adenoid layer 
is made clear by the large number of nuclei in it. (Heymann.) 1, glandular 
excretory duct ; 2, epithelium ; 3, basement membrane ; 4, adenoid layer ; 5, peri- 
osteum, elastic layer ; 6, periosteum, cellular layer ; 7, bone ; 8, bone ; 9, glands. 



PLATE YII. 







I 




# 



ANATOMY AND PHYSIOLOGY OF* THE NOSE AND NASOPHARYNX. 235 

The epithelial lining of the raspiratory mucous membrane, or mucous 
membrane proper, of the nasal fossse is a columnar epithelium of several 
layers, the topmost layer of which is ciliated. The cells are long and 
spindle-shaped and interspersed with goblet-cells, which are epithelial 
cells in a state of mucoid degeneration. The thickness of the epithelial 
layer is from thirty to seventy micromillimetres. The cilia in the sinuses 
wave towards the outlets of these cavities. The cilia of the nasal fossae 
wave towards the i:)Osterior nares. The cilia move in a thin layer of 
fluid, not in the air. The epithelial layer is thinnest in the sinuses. 

Tubular mucous glands are present in great numbers in the mucous 
membrane of the nose. They are convoluted, branching, or single tubes, 
and may be superficial or reach clear to the periosteum. Each gland 
is surrounded by a homogeneous membrane, the inembrana propria, a 
continuation of the basement membrane of the ciliated epithelium. The 
openings of the glands may be at right angles to the surface, or they may 
reach it obliquely if the gland runs for some distance under the surface. 
The glands are lined with a single Vdjev of tall columnar epithelium 
interspersed with goblet-cells. Under the ciliated epithelium of the 
mncous surfiice there lies a homogeneous basement membrane. Below 
this there is a connective-tissue layer of many interlacing fibres continu- 
ous with the i)eriosteum. Tlie submucous connective tissue and the epi- 
thelium contain varying amounts of leucocj'tes and lymphoid collections, 
called adenoid tissue, also lymph-follicles. The submucous tissue and 
X^eriosteum contain varying amounts of elastic fibres. 

The homogeneous basement membrane is perforated by many fine 
canals which connect the intercellular spaces of the submucous connec- 
tive tissue with the epithelium. Leucocytes pass through these canals 
into the epithelial layer, and fluids find their Avay through them to moisten 
the surface. These little canals have a diameter of from two to three 
micromillimetres, and are much narrower than the capillaries. They 
are very numei'ous at times, only one or two epithelial cells intervening 
between two canals. They do not connect directly with the lymjDh- 
channels, but only with the spaces between the connective-tissue cells of 
the submucous tissue. These si^aces can be best seen in sections made 
from hypertrophied mucous membrane. The function of these inter- 
cellular spaces and the canals of the basement membrane is i^robably to 
supply the great amount of moisture furnished by the surface of the 
nasal passages and needful to prevent the mucous membrane from drying, 
and to keep the inspired air sufficiently saturated with watery vapor. 

The circulation of the nasal mucous membrane is complex. There 
are three sj'stems of capillaries, — first, i^eriosteal, then those forming a net- 
work around the mucous glands, and finally those sujDplj^ing the surface 
of the mucous membrane. The veins are everywhere large in caliber, 
while the lumen of the arteries is unusually small. 

The most remarkable x>art of the nasal circulation is the so-called 



236 



DISEASES OF THE NOSE AND NASOPHARYNX. 



erectile tissue, found on tlie inferior turbinated body, the free border and 
posterior end of the middle turbinated, and the posterior end of the 
superior turbinated body. The raj)idity with which swelling of the tur- 
binated bodies can take place is familiar to all those who inspect the 
nares rhinoscopically. The swelling may go away as fast as it came, 
especially under the influence of cocaine or fear of operation. These 
changes are due to dilatation or contraction of the erectile tissue. The 
arrangement of the blood-vessels in the erectile tissue is as follows. 
First there are the arteries with the three divisions into capillaries, peri- 



FiG. 95. 









^~- 


--- 




V / 


i 






s^/ 


; 


/ 




J 


\\ 




/^ 




1 




1 




/ 


\ 


I 



\ 1/ u 






/ ^ % ;r^ 



,' ^\,. 



a 



Olfactory supporting cells. (Heymann, after Schiefferdecker.) 1, -unexplained deposit ; 2, membrana 
limitans ; 3, supporting cell ; 4, olfactory cell. 



osteal, glandular, and sui^erficial. These capillaries unite to form small 
veins, which empty into the larger lacunar veins of the erectile tissue. 
These empty into a third system of veins of the ordinary type. The 
large veins of the erectile tissue have a very thick muscular coat, un- 
like that of any other vein. Its muscular fibres interlace in every 
direction, though most of them are circular. The smooth muscle -fibres 
also extend into the connective tissue about the veins. The erectile 
tissue is found in a layer between the periosteal layer and the superficial 
portion of the mucous membrane. When the veins of the erectile tissue 
dilate by reason of relaxation of their muscular coats, a large amount of 



ANATOMY AXD PHYSIOLOGY OF THE XOSE AXD XASOPHARYXX. 



23: 



blood is retained in them, which in cooling warms the respired air. This 
warming of the air is sui)posed by some to be the function of the erec- 
tile tissue. There is no analogy as to structure between the tissue of the 
l^enis and the erectile tissue of the nose. 

The olfactory mucous membrane found in the regio olfactoria — a 
region placed by most authors on the upi)er surface of the middle tur- 
binate and opiDOsite wall of the sei^tum — has a peculiar histological struc- 
ture. The epithelium is composed of columnar epithelial cells with 
branching base and a large nucleus. Between these epithelial cells, 
called supporting cells, are found the nerve- cells of the special sense of 
smell, or olfactory- nerve- cells. The supi)orting cells are not ciliated, but 
end above in a flat membrane called the membrana limitans, while the 
olfactory cells terminate in a little bunch of from six to eight hair-like 




Transverse section through the olfactory mucous membrane of a man of thirty. (Hej-mann, after 
vonBraun.) 1, Bowman's glands stained with silver; 2,2, olfactorj- fibres, one of which is in connection 
with an olfactory cell (o) ; 4. basement cells. 



processes which project above the surface of the limiting membrane. 
The olfactory cells are connected directly with a fibre of the olfactory 
nerve. They have a large nucleus, which gives the cell-body a spindle 
shape. Underneath the top layer of supi^orting cells are several layers 
of epithelial cells, called basal cells, of structure like the supporting cells. 
It is probable that the olfactory mucous membrane has no ciliated 
epithelium. 

The upper ends of the supporting cells have a yellow pigment, which 
has given to the olfactory region a yellow color and the name locus luteus. 
The connective-tissue cells of the stroma beneath the epithelial layer in 
the olfactory region also have a yellow pigmentation. 

The mucous glands of the olfactory region differ from those of the 
respiratory mucous membrane. They are very simple tubular glands, 



238 DISEASES OF THE NOSE AND NASOPHARYNX. 

with usually two branches. Their epithelium is very low, and they 
secrete a serous fluid, while the glands of the respiratory region are mu- 
ciparous. The glands of the olfactory region are named after Bowman. 

There is no basement membrane underneath the epithelium in the 
olfactory region ; the cells lie directly on the connective tissue. In the 
toi^most layers of this are found collections of leucocytes, which lie just 
under the epithelium, forming a layer of adenoid tissue with occasional 
lymi3h-follicles. The blood-vessels of the olfactory region present nothing 
remarkable. The nerves are for the most part derived from the olfactory 
nerves 5 fibres from the fifth pair are also found. The lymphatic system 
of the nasal mucous membrane connects with the subarachnoid and sub- 
dural spaces from which its vessels have been injected. 

PHYSIOLOGY OF THE NOSE. 

The Respiratory Function. — Paulsen's experiments have shown that the 
current of air during insj)iration at first passes nearly directly upward 
under the dorsum nasi, then follows the roof of the nasal fossse, the 
chief part of the current flowing through the middle and upper meatuses 
and descending behind to the choanse. In expiration the air takes the 
same course, with the direction reversed. The act of inspiration creates 
a negative pressure in the nose, so that at the beginning of inspiration 
air leaves the posterior nares before it commences to enter the nostril. 
Expiration causes a positive pressure, so that air enters the posterior 
nares before any begins to leave the anterior openings of the nose. The 
air in the accessory sinuses is subject to the same changes of pressure as 
that in the nasal fossse, so that in consequence there is a slight current of 
air leaving and entering them, which becomes increased during strong 
inspiratory or expiratory efforts. The smallness of the openings to the 
accessory sinuses prevents any strong current of air from entering them. 
The changes of atmospheric pressure in the nasal fossae and antrum of 
Highmore have been measured with a manometer. In the nasal fossae 
they have been found equal to sixty millimetres of mercury during strong 
inspiration ; in the antrum equal to eight millimetres of water. In passing 
through the nasal fossse the air becomes saturated with moisture to nearly 
or quite its full capacity. This has been proved by experiments. The 
air- current also becomes warmed in passing through the nose, under or- 
dinary conditions, to 86° F. In mouth-breathing there is a sensation of 
cold in the throat that does not accomx)any nasal respiration. 

Though the nasal passages have but a short course, their mucous sur- 
face is of very great extent, while the air passes over it through nar- 
rowed and tortuous fissures. The mucous membrane also has a very free 
vascular supply, as described above, which favors radiation of heat and 
su]3]3lies abundant moisture. All these conditions account for the great 
amount of warmth and watery vapor supplied to the air-current on its 
way through the nasal fossae. For the same reasons the deposit of dust 



ANATOMY AND PHYSIOLOGY OF THE NOSE AND NASOPHARYNX. 239 

on the nasal mucous surface is favored, and, though some dust escax^es 
and nmst pass through to the pharynx, the position of the posterior 
pharyngeal wall at right angles to the air-current will arrest much of the 
remainder. Some dust is sure to reach the lungs ; nevertheless, the nose 
and pharynx will retain all but a very small amount of the particles 
passing through them. In mouth-breathers these favorable conditions 
obviously do not exist. The long, indirect course taken by the air- 
current also favors dust deposit in the nose. The particles adhere to the 
mucus, and are gradually moved along by the cilia of the epithelium to- 
wards the pharynx. The normal reaction of the nasal mucus is alkaline, 
and its viscidity i^rotects the epithelium and its cilia from injury. 

The firm, bony walls of the nasal fossae and cartilaginous external nose 
resist the negative atmospheric pressure, and cannot be sucked in during 
inspiration. The al?e nasi, however, do not resist, and would collapse 
were it not for the dilating x^ower of their muscles, which act rhythmi- 
cally at the beginning of each iusi^iration. 

The nose is an organ of voice. Xasal obstructions injure the reso- 
nance of the voice, as the column of air in the nose does not vibrate with 
that in the throat. The effect of partial or complete closure of the nasal 
passages in x^roducing a dead voice is most markedly noticeable after the 
removal of nasal x^o^ypi? hyX^ertrox^hies, septal sx^urs, and deflections. 
After removal of the nasal obstruction the voice acquires a clearness 
and ring which are striking. People who all their lives have been con- 
scious of a disagreeable nasal voice may have this objectionable quality 
entirely' removed in a few minutes. 

Olfactory Function. — The sense of smell, tliough the least imx:>ortant 
of the sx:)ecial senses, is still of great consequence to the iu dividual. 
Like the other senses, it furnishes its share of x^l^^^surable emotions and 
acts as a sentinel in case of danger. The nerve- cell of the olfactory 
region has for its dendrite the terminal hairs described. These either 
end free in the air or more x^i'obably are contained in the fluid from 
Bowman's glands, a fluid x^resumably of specific quality intended to 
subserve the olfactory sense. From the terminal hairs the nerve- imx^ulse 
is conveyed to the nerve-cell, which is a ganglion cell ; there it is con- 
verted into the specific sensation and conveyed by its neuraxis to the 
olfactory bulb. Thence it is carried through a series of neurons to the 
cerebral cortex and consciousness. 

Odors reach the nose in the form of gases, vax^ors, fluid particles (fog), 
and as dust. It is x^robable that the substances causing odors must reach 
the olfactory hairs in chemical solution in order to x^roduce the sense of an 
odor. Inconceivably small amounts of aromatic substances are cax:)able 
of producing a percex^tible odor, as, for instance, ttooVfoo of a milli- 
gramme of mercaptan to a litre of air. The sense of smell is very readily 
exhausted ; in a few minutes an odor that was decidedly noticeable maj^ 
cease to be recognized. Some individuals may be unable to smell certain 



240 DISEASES OF THE NOSE AND NASOPHARYNX. 

substances at all, — a condition of partial anosmia analogous to color- 
blindness. It is a rare condition. In subjective parosmia the individual 
has a x^erception of an odor where none really exists. This state is due 
to disorder of the olfactory nerves or olfactory centre in the brain, and 
is quite common in the insane. These subjective odors are apt to be of 
a disgusting character. 

Among the nasal reflexes the most familiar is the act of sneezing. 
The reflex of sneezing is easily excited by irritation of the anterior and 
posterior ends of the two lower turbinated bodies and the corresi)onding 
part of the septum. It seems as if the region of the middle meatus were 
a location irritation of which by probes and instruments is especially 
liable to cause sneezing. Francois Frank has produced spasm of the 
glottis and of the bronchi by irritation of the nasal mucous membrane. 
Lazarus also found that the lumen of the bronchi diminished under the 
same conditions. The impulse here is carried to the muscles of the 
bronchial walls through the pneumogastric nerve. Irritation of the sur- 
face of the nasal cavity may also cause expiratory arrest of respiratory 
movements. This constitutes a danger in the early stage of chloroform 
narcosis, especially if associated with spasm of the glottis. The reflexes 
described above i^rotect the individual from the entrance of foreign 
bodies into the air-passages. Sneezing expels them from the nose, spasm 
of the glottis prevents their x^assing down the windx^ixDc, and narrowing of 
the bronchial tubes keeps them from entering these. Another tyj)e of 
vasomotor reflexes is that in which irritation of the neighboring cuta- 
neous surface causes contraction of the vessels of the nasal mucous 
membrane, as cold ai^plications to the neck in nose-bleed. Vicarious 
menstruation is a type in which the reflex from distant organs causes 
dilatation of the vessels of the mucous membrane. A great many things 
have been attributed to nasal reflexes, such as neuralgias, migraine, etc. 
It is hard to tell whether the relief of these states obtained by nasal 
treatment is due to suppression of abnormal reflexes or to suggestion. 
There is a proneness to overestimate the number of morbid states result- 
ing from nasal reflexes, and often — as in asthma, for example — one is 
disappointed by finding that removal of the nasal disease causes no im- 
provement in the supposed reflex. 

ANATOMY OF THE NASOPHARYNX. 

The bones to which the nasopharynx is attached are the body of the 
S]3henoid bone, the basilar process of the occipital bone, the j^etrous x)or- 
tion of the temporal, and the internal j)terygoid plate of the sphenoid 
bone. The basilar fibrocartilage, a thickening of the periosteum, covers 
the basilar i)rocess of the occipital bone and the body of the sphenoid, 
and, extending outward, fills the petro-occiiDital fissure and the foramen 
lacerum, and is lost in the periosteum of the petrous portion. 

The basilar fibrocartilage is continuous with the fascia pharyngo- 



ANATOMY AND PHYSIOLOGY OF THE NOSE AND NASOPHARYNX. 241 



basilaris. This is the fascia of the pharynx proper, and lies under the 
mucous surface, hanging like a tube from the base of the skull. Ex- 
ternal to the fascia of the i^harynx there is its superior constrictor muscle 
originating from the border of the choana and the hamulus pterygoideus. 
The sui)erior constrictor does not extend as high up as the fascia of the 
pharynx, but reaches to a point below the anterior arch of the atlas. 
External to the superior constrictor is the stylopharyngeus muscle. The 
levator palati muscle has its origin from the petrous i:)ortion of the 
temporal bone and the Eustachian tube, to the membranous floor of 
which it is attached. It passes 

downward, forward, and inward Fig. 97. 

behind the tube, and is inserted 
in the shape of a fan into the soft 
palate. This is the muscle whose 
motion is visible during phona- 
tion if the nasal passages be suf- 
ficiently roomy to permit one to 
see into the j)harynx. The leva- 
tor i^alati and superior consti'ic- 
tor are supplied by the plexus 
pharyngeus. 

The tensor palati originates 
along the anterior wall of the 
Eustachian tube from the great 
wing of the sphenoid, its origin 
extending from the spina angu- 
laris to the inner pterj'goid plate ; 
its tendon passes around the 
hamulus pterj'goideus to be in- 
serted into the aponeurosis of the 
soft palate and wall of the phar- 
ynx. It is supplied by the nerviis 
pterygoideus internus. The mus- 
culus uvulse originates from the 

aponeurosis of the soft palate, near the posterior nasal spine, and extends 
as a cylindrical muscle to the uvula. It is supplied by the plexus 
pharyngeus. The salpingopharyngeus muscle originates from the soft 
palate and Eustachian tube and passes backward to be inserted into the 
fascia pharyngobasilaris. It is supplied by the plexus pharyngeus. 

The internal carotid artery and the internal jugular vein external 
and i^osterior to it are separated from the lateral wall of the nasopharynx 
by an interval of three-quarters of an inch, and are nowhere in contact 
with it. The intervening space is filled in with connective tissue. 

The blood-supply of the lateral wall of the nasopharynx is exceed- 
ingly rich, while the roof contains no blood-vessels of any size. This 

16 




Cornu Via I 
«si hyuu 



Cart 
)i'i isherj 

Cart 
Santo rill 



The muscles of the soft palate, posterior view. 
(Brcsgeu.) 



242 DISEASES OF THE NOSE AND NASOPHARYNX. 

accounts for the slight hemorrhage occurring during operations for ade- 
noid vegetations. Though the blood flows freely at first, it always ceases 
in a little while, as no vessels of any size have been severed. Should 
the inexperienced operator wound the Eustachian tube or lateral pharyn- 
geal wall, the hemorrhage might prove uncontrollable. 

The lymph-vessels from the dorsum of the soft palate connect with 
those of the nose, from its ventral surface with those of the tongue. 
These lymph-vessels unite to form main trunks that empty into the 
carotid lymph-glands. The lymph-glands of the upper pharynx empty 
into glands in the posterior pharyngeal wall and into some glands situ- 
ated on the great horn of the hyoid bone. The sensory nerves of the 
nasopharynx are derived from the pharyngeal plexus formed by the 
vagus, spinal accessory, and glossopharyngeal nerves. The soft palate 
also receives sensation from the second division of the fifth pair of cranial 
nerves. 

General Description of the Nasopharynx. — The roof or vault of the 
IDharynx reaches from the upper border of the choanae to the pharyngeal 
tubercle of the occipital bone. The posterior wall is continuous with the 
roof, their surfaces being joined by a curved angle. The posterior wall 
of the pharynx extends from the pharyngeal tubercle down to the lower 
border of the anterior arch of the atlas. The roof and posterior wall of 
the nasopharynx contain no muscles, the mucous membrane resting 
directly on the basilar fibrocartilage as far as this extends, while the 
posterior wall of the pharynx is separated from the atlas and articulations 
between this and the occipital bone by loose areolar tissue. The vault 
of the pharynx contains a structure of great pathological importance, 
the third or Luschka's tonsil. Up to puberty this is usually normally 
developed, but in adults it ordinarily disappears by atrophy, or its rudi- 
mentary remains alone are present. Luschka's tonsil consists of six or 
seven longitudinal ridges of lymjohoid tissue separated from one another 
by sulci ; the central sulcus is the deepest. Laterally the third tonsil 
reaches as far as the vault of the pharynx extends, or to the fossa of 
Eosenmiiller 5 posteriorly it extends to the foramen ovale ; anteriorly 
its margin is the upper border of the choanse. In pathological cases 
portions of the third tonsil are found in the posterior nares, arising from 
the upper and lateral borders of the choanse, a fact of great importance 
in regard to the operation for adenoid vegetations, and one which will be 
considered in its description. 

The mucous membrane in the region of the third tonsil is friable, 
thick, and soft, and has a grayish-red color. Back of the pharyngeal ton- 
sil there is occasionally found a pocket in the mucous membrane extend- 
ing deeply to the occipital bone. It is called the bursa pharyngea. The 
junction of the roof and lateral walls of the nasopharynx posterior to 
the Eustachian tube creates a deep recess called the recessus pharyngeus, 
or fossa of Eosenmiiller. Anterior to the fossa of Eosenmiiller the 



ANATOMY AND PHYSIOLOGY OF THE NOSE AND NASOPHARYNX. 243 

Eustachian tube can be seen jutting from the lateral i^haryngeal wall. 
The direction of its canal is downward, forward, and inward. It may 
open in the shape of a funnel or as a narrow triangular slit. The ex- 
tremity of the Eustachian tube is removed from the posterior end of the 
inferior turbinal bj' about one-fourth of an inch. When the soft palate is 
raised it closes the nasopharynx below and forms its floor. The anterior 
boundary of the nasopharynx is formed by the posterior nares. 

Histology of the Xaso])liarynx. — Ciliated eijithelium in a single or in 
several layers lines the interior of the nasopharynx and back of the 
velum i:)alati. On the posterior wall ciliated epithelium extends in chil- 
dren as far down as the level of the soft i:)alate ; in adults only down to 
the level of the upper border of the superior constrictor of the pharynx. 

Fig. 98. 




3 4 

Transverse section of the pharyngeal tonsil of a one-year-old child. (Heymann.) 1, epithelium; 
2, propria ; 3, glands ; 4, basilar fibrocartilage. 



Below this the ciliated epithelium merges into pavement epithelium. 
Beneath the epithelium there i-s a basement membrane and, as far as the 
ciliated epithelium extends, no pai^illa?. The pharj^ngeal mucous mem- 
brane contains many elastic fibres and mucous glands which are especially 
numerous on the pharyngeal vault. 

The minute anatomy of Luschka's tonsil requires especial attention. 
It is simply a thick mucous membrane of the same structure as that 
found elsewhere in the nose and nasopharynx, with the lymphoid element 
so pronounced as to overshadow the other elements. There is. there- 
fore, no essential difference between the structure of the third tonsil and 
that of the rest of the nasal and nasopharyngeal mucous membrane, so 
that it can readily be understood why adenoid vegetations are often found 
within the openings of the posterior nares. 



CHAPTER 11. 

THE EXAMINATION OF THE NOSE AND NASOPHARYNX. 
EXAMINATION OF THE NOSE. 

The examination of the external nose obviously requires no special 
methods. The surgeon can estimate the capacity of each nostril for the 
passage of air by closing its fellow with the finger and listening to the 
sound made by breathing. Air passing through a clear nasal fossa causes 
almost no sound, but if there be an obstruction of even moderate degree 
there is a sound of a stenotic, hissing character. This method is of value, 
because it is not always possible to see the cause of a nasal obstruction, 
if far back, for posterior rhinoscopy cannot always be used. 

A head-mirror, of the kind used in laryngoscopy, preferably of a diam- 
eter of four inches, is necessary for rhinoscopy as ordinarily performed. 
It is better to concentrate the rays of the light used with a condenser, but 
not absolutely necessary. The reflector can be replaced by one of the 
modern miniature electric lights with condensing lens worn on the fore- 
head. The chief advantage of these lights lies in their making the 

person performing rhinoscopy 
^^^'- ^^' independent of a source of 

light to reflect from, so that 
the examiner's head can be 
approached close to the pa- 
tient's face or withdrawn from 
it without interfering with the 
^ , . , , , , ^, , , . focus, as when the mirror is 

Ingals s nasal speculum (three-fifths natural size). ' 

used, and it also saves the 
patient the annoyance of the heat of the gas-flame. Six-volt lights are 
the most practical, and the cylinder containing the light and its con- 
densing lens should never exceed five- eighths of an inch in diameter. 
The reason for this is that the rays leaving a wide cjdinder form an 
angle with those returning to the eye from the illuminated object, so 
that it is impossible to see to any depth, while the axis of a narrow 
cylinder can be placed so close to the axis of the eye that the angle 
formed by the projected and returning ray is of no consequence, as the 
rays are for all practical purposes parallel. Most of the cylinders fur- 
nished by mechanics are too wide, their idea being to give a large illu- 
minated field by means of a large lens, while all that is needed is a spot 
of light one and one-half inches in diameter. 

Of all the many styles of nasal specula in use the most satisfactory 
is the simple bivalve form. The one shown in Fig. 99 has proved most 
serviceable for examinations and operating. 
244 




THE examinatio:n^ of the nose and nasopharynx. 245 

The first step in rhinoscopy is the inspection of the vestibule of the 
nose without a speculum, as there are often found eczematous crusting, 
patches, and fissures in this region which render examination with a 
speculum inadmissible by reason of its painfulness. Little children fear 
a speculum, and, as their vibrissas are undeveloped, it is usually easy to 
inspect infantile nasal passages without an instrument. The nasal specu- 
lum is to be opened gently, as its rough use causes a good deal of x)ain. 
The examiner's head should be so placed that his eyes are on a level 
with the inferior meatus. The foreshortening in the appearance of the 
parts makes the aspect of the nasal interior rather confusing to those 
unused to seeing it, as everything is viewed ai)parently on edge. It is 
well to follow a systematic course in making a nasal examination, other- 
wise it is easy to overlook something in inspecting the complicated nasal 
fossae. 

The object first noticed is usually the inferior turbinated body, which 
presents as a reddish prominence above the inferior meatus, larger or 
smaller according to the amount of distention of its erectile tissue. If 
the inferior turbinated body be small or retracted, the examiner can often 
look into the nasopharynx, recognizable by the motions of the levator 
palati in phonation. The middle turbinated body can be seen above the 
lower, usually pale in color and more translucent than the lower one. 
It lies close to the septum, separated from it by the narrow olfactory 
fissure, and is visible for about one-half its length. The superior tur- 
binate and meatus are invisible from in front. The septum usually 
presents a deflection to one or the other side, and is often marked 
by prominent ridges or spurs. To determine its thickness a septom- 
eter may be used, — a calii^er-like instrument. At the level of the an- 
terior end of the middle turbinate and a little in front there is a soft 
prominence of the mucous membrane of the septum, capable of swell- 
ing, as does the inferior turbinate, called the tuberculum septi. It 
retracts under cocaine, and its irritation easily arouses sneezing. It may 
swell enough to cause nasal obstruction at times and require cauteriza- 
tion. The nasal floor presents nothing of interest. Where the middle 
turbinated body is rudimentary it is possible to see the hiatus semilu- 
naris, processus uncinatus, and bulla ethmoidalis. The lachrymal duct is 
invisible. The various pathological conditions to be seen in the nose 
will be considered with the diseases that give rise to them. A light and 
flexible probe is indispensable in rhinoscopy, for with it the examiner 
can tell whether a swelling be soft or hard, fixed or movable, and whether 
carious bone or a foreign body be present. It also informs the surgeon 
whether there are sensitive regions from which morbid reflexes originate, 
such as spasmodic sneezing or asthma. It is possible, in a certain per- 
centage of cases, to pass a probe into the accessory sinuses, but the only 
sinus opening directly visible, and that only in a small proportion of 
cases, is the sphenoidal sinus. 



246 



DISEASES OF THE NOSE AND NASOPHARYNX. 



EXAMINATION OF THE NASOPHARYNX. 

Fosterior BMnoscopy. — In order to see the nostrils from behind, a mirror 
must be placed back of the soft palate to reflect light into the nasophar- 
ynx. The largest mirror that can be used is the proper one to employ, 
but usually a l^o. 1 or ^o. 2 is as large as one can introduce back of the 
soft palate, and in children No. or even 'No. 00 has to be employed. 
The larger the mirror the more intense the illumination of the visible 
parts. Many palate hooks and retractors, special mirrors, and other 
instruments for posterior rhinoscopy have been devised, but most rhi- 
nologists prefer simply a tongue-depressor, a laryngeal mirror, and a 
head-mirror. Palate-retractors are useful in operations, but rather an 
impediment than otherwise during examinations, as the reflex spasm of 

the soft palate they excite ele- 
^^^- ^^^' vates it to the pharyngeal vault 

and makes a view of , the pos- 
terior nares impossible. 

It is well to have two or three 
mirrors at hand, bent on their 
wire handles at various angles 
so that their surfaces can be 
more readily directed towards 
the lowest or highest parts of the 
nasopharynx. The stem of the 
mirror should have a slight 
curve, presenting its concavity 
towards the tongue. The patient 
should hold his head erect or 
slightly inclined forward. When 
the tongue -depressor is intro- 
duced he should be told to let 
his tongue yield to its downward 
pressure. This is a very effective suggestion, as otherwise he is liable 
to defeat the surgeon's efforts by pressing the tongue up against the roof 
of the mouth. For some patients it is better to use no tongue-depressor. 
The mirror must be warmed and passed back with the reflecting surface 
upward. The stem should rest nearly on the lower incisor teeth and lie 
on the back of the tongue, if no tongue-depressor be used. Care must 
be used in passing the mirror back of the soft palate to touch nothing, 
so that no reflex spasm of the muscles of the throat will be caused. 
The posterior pharyngeal wall is the least sensitive of the parts encoun- 
tered, and in many cases the mirror can be placed against this without 
exciting retching ; it is better, however, to avoid actual contact with it. 
If the handle of the mirror be depressed the inferior meatus comes into 
view. As the handle is slowly raised the middle meatus, the upper 




Position for posterior rhinoscopy. 



THE EXAMIXATION OF THE NOSE AND NASOPHARYNX. 



247 



arclies of the choanae, and finally the vault of the pharynx are seen. To 
see all of the latter, however, a mirror attached to its stem at an obtuse 
angle is needed. The obstacles to posterior rhinoscopy presented by the 
tongue can usually be overcome in the way mentioned above. To avoid 
a long or voluminous uvula one must be satisfied with a mirror so small 
that it can be placed in the space on either side of the obstacle. 

When the fauces and tongue are so irritable that touching them causes 
retching, this can ordinarily be overcome by spraying them with a five 
per cent, solution of cocaine. At times, however, the throat is so 
prone to convulsive action that the taste of the cocaine excites vomit- 
ing, and the mere approach of the mirror to the fauces, even without 
contact, causes spasm. Here nothing but frequent examinations and 



home will school it to be tolerant 



Fig. 101. 
1 



practice in touching the throat at 
of instruments. Xearness 
of the soft palate to the 
posterior pharyngeal wall 
may cause insurmountable 
difficulties, as here there 



is no space to reflect light 
into the nasopharynx. In 
other cases involuntary 
contraction of the soft pal- 
ate will raise it and place 
it close to the posterior 
wall of the pharynx. Here 
the patient is to be told to 
breathe through his nose 
and mouth at the same 
time. Some cannot ac- 
complish this, and for 
these a cocaine spray will 
usually deaden the reflex 
that causes the elevation 
of the soft palate. 

Satisfactorj^ posterior 
rhinoscopy is more diffi- 
cult than laryngoscopy, as 
used, the image is more imperfecth' illuminated, the smallness of the 
field seen at one time makes it harder to recognize, and as only a little 
of the part to be examined can be seen, the mirror must be moved about 
so as to get a piecemeal conception of the whole, and this is liable to 
bring the mirror in contact with irritable x:»arts and cause retching. 

The parts first to be sought for are the septum narium and the choanse, 
as these give the most striking and readily recognizable image. The 
septum narium bisects vertically the rhinoscopic view, presenting a thin, 




Posterior nares. (M. Schmidt.) 1, recess of the pharyngeal 
tonsil ; 2, pharyngeal recess (Rosenmiiller's) ; 3, mouth of the 
Eustachian tube ; 4. posterior lip of the Eustachian tube ; 5, 
superior turbinate ; 6, middle turbinate ; 7, inferior turbinate; 
8, uvula. 



to the small mirrors which have to be 



248 DISEASES OF THE NOSE AND NASOPHARYNX. 

clean-cut edge at its lower part, but widening evenly above. Its color 
is pale j)ink or yellow in its lower portions^ but redder in the upper 
part, where it has the color of the mucous membrane of the pharyngeal 
vault, while its sides are grayish pink. From the septum the upper 
border of the choanse sweeps outward in an arch, curving downward and 
finally inward, joining the sex)tum again below and forming the two oval 
openings of the posterior nares. Framed by these from above downward, 
on the outer w^all of the nose are seen the upper, middle, and inferior 
turbinals. 

The superior turbinal is usually covered by the large middle turbinal 
so as to be invisible. It is farther forward in the nose than the middle 
turbinal, and is a pale red iDrominence whose borders are not to be seen. 
The middle turbinal is of a light yellowish or grayish red, and the most 
conspicuous of the three. The inferior turbinal ai3j)ears as a rounded 
prominence, and is of a light gray or pink color. In many cases it is 
hard to see, being often hidden by the iDartly raised soft palate, but when 
this occurs, thorough cocainization will help to make it visible. Yol- 
tolini uses two mirrors in these cases in order to see the inferior turbinal 
and meatus. He introduces one high in the pharyngeal vault and 
catches its image with a lower one. Of the three meatuses the upper 
is the largest as seen from behind, the middle decidedly smaller, the 
lowest almost invisible, as a rule. The Eustachian orifice on each side is 
found external and posterior to the inferior turbinated body, usually on 
a level with the middle meatus, but sometimes slightly above or below it. 
The opening has an irregularly triangular or crescentic shape, and looks 
downward, inward, and slightly forward. It is bounded by two more 
or less prominent projections, called the anterior and posterior walls or 
lips of the Eustachian orifice, which are covered with pale red or yellow- 
ish mucous membrane. In some peoj)le the lips of the Eustachian orifice 
are large and jut i)rominently into the nasopharynx, in others they are 
almost level with the lateral pharyngeal wall and are hard to see. 

The back of the uvula and soft palate can be seen only when the 
rhinoscopic mirror is held high behind the velum while the latter is 
comi^letely relaxed ; then in the median line the elevation caused by the 
uvularis muscle can be seen. The posterior pharyngeal wall becomes 
visible if the handle of the mirror be raised, but it is so much fore- 
shortened that its inspection is unsatisfactory, especially if the promi- 
nence caused by the atlas be marked. In the perspective view which is 
obtained of this part in rhinoscopy the vault of the pharynx appears 
shorter than natural. The mucous membrane is of a light red color, 
broken on its surface into irregular, more or less longitudinal fissures and 
ridges, which give it much the appearance of the surface of the faucial 
tonsil. This ai)pearance of the surface is due to the adenoid tissue in the 
mucous membrane of the pharyngeal vault, and is the third or Luschka's 
tonsil. In adults the rigid surface of the third tonsil disappears and the 



THE EXAMIXATIOX OF THE NOSE AND NASOPHAEYXX. 249 

surfiice of the pharyngeal vault is comparatively smooth, as the third 
tonsil has atrophied. The third tonsil becomes of a pathological size as 
soon as it causes disturbances, such as interference with nasal respira- 
tion or deafness by preventing the ventilation of the middle ear. It 
will often do this by closing the Eustachian orifice when it is not large 
enough to obstruct breathing. 

Digital examination of the nasopharynx is of great value in diagnosis 
when the surgeon Avishes to determine the consistency of tumors, or when 
posterior rhinoscopy is unsatisfactory or impossible. 



CHAPTER III. 

ACUTE RHINITIS AND HAY FEVEE. 
SIMPLE ACUTE RHINITIS. 

Synonymes. — Acute coryza, acute nasal catarrh, acute rhinorrhoea, acute ca- 
tarrhal rhinitis, acute cold in the head. 

Simple acute rhinitis is an acute inflammation of the mucous mem- 
brane of the nose, varjang greatly in cause and degree. It has a ten- 
dency to invade neighboring parts of the respiratory tract, and is char- 
acterized by a tumefaction of the mucous tissues that is apt to vanish 
and reappear, while the mucous membrane, at first dry, soon furnishes a 
free watery discharge which later becomes opaque, due to the admixture 
of epithelium and leucocytes. 

Anatomical and Fathological Characteristics. — The mucous membrane is 
dry in the early stage, not swollen, and of a light red color. This soon 
changes to a deep red, and swelling takes place, especially in the cavern- 
ous tissue of the turbinated bodies, the tumefaction being soft and elastic, 
so that the probe readily sinks into it. The swelling may be found so 
intense that the turbinals touch the septum, while perhaps a short time 
after the nasal passages will be almost free. In the majority of cases 
the tumefaction is therefore less a true inflammatory oedema than a dis- 
tention of the lacunar veins of the erectile tissue. When oedema occurs 
abundant discharge takes place, being at first serous, then mucous, and 
finally mucopurulent.' In ordinary simple rhinitis tbe floor of the nose, 
the meatuses, and the septum show but little swelling, with the excep- 
tion of occasional tumefied patches. In the form of acute rhinitis due to 
infection with pus-forming microbes, such as gonococci, streptococci, or 
the contagium of scarlatina, — a form which is called blennorrhagic rhi- 
nitis or rhinitis blennorrhagica, — the entire nasal mucous membrane is 
in a state of inflammatory oedema and of a deej) scarlet color, while pus 
and blood can be seen flooding the recesses of the nose. Small erosions 
extending through the epithelial surface are occasionally seen, especially 
at the nasal entrance. Microscopically, the discharge at first contains 
only leucocytes, but later, as the epithelial cells begin to be shed in 
abundance, they contribute greatly to the opacity of the nasal secretion 
which characterizes the later stages of a cold in the head. Cylindrical, 
ciliated, and pavement epithelium, pus-cells, and red corpuscles appear 
in the discharge, together with numerous bacteria. In the early stage of 
acute rhinitis the changes in the epithelium are limited to loss of cilia 
and in places of the ciliated cells themselves. The subepithelial tissues, 

250 



ACUTE RHINITIS AND HAY FEVER. 251 

the neighborhood of the mucous glands, and the epithelium also are 
markedly infiltrated with lymphocytes. These are mostly eosinophile 
cells, while those penetrating the epithelium are wholly of this order. 
Later the superficial layer of the epithelium undergoes mucoid degen- 
eration and is cast off from large areas. This occurs very extensively in 
the severe rhinitis of influenza, and the epithelial cells of the mucous 
glands also degenerate and desquamate. The veins of the mucous mem- 
brane, esi)ecially where there is erectile tissue, are found greatly dilated 
down to the periosteum ; the capillaries are also full of blood, and ex- 
travasations of red blood-cells into the tissues and their passage through 
the epithelium occur in the higher grades of inflammation. The adenoid 
layer — that is, the layer of leucocytes normally found just under the base- 
ment membrane — is much increased in quantity and oedematous and its 
interstitial spaces distended with serum. The olfactory region ordinarily 
shows no swelling, but hyperaemia and desquamation of the epithelium 
and emigration of leucocytes occur here. It does not seem, however, 
that this region is as liable to pathological changes as the respiratory 
portion of the nasal mucous membrane. 

Etiology. — Nervous temperament and scrofulous diathesis are com- 
monly considered i)redispositions to acute nasal catarrh. The disease is 
so common, however, among people in all states of health that these 
factors are probably of limited consequence. It is certain that those 
who lead out-of-door lives and are endowed with vigorous muscular 
bodies are less liable to acute rhinitis than those with indoor occupations 
and feeble constitutions. Children and young adults are especially prone 
to the disease, while in old age it is comparatively infrequent. 

Local ]3redisposing causes are nasal obstructions of all kinds, nasal 
mucous polypi, septal deviations, adenoid vegetations in children, chronic 
hypertrophic and intumescent rhinitis. It is probable that the increased 
intranasal negative pressure due to these conditions acts as a cause by 
producing a venous hyj)eroemia. As adenoid tissue in the nasopharynx 
is the seat of frequent acute infectious inflammatory states, and as these 
are often the starting-points of an acute rhinitis, the frequency of the 
disease in children may in part be accounted for when it is remembered 
that adenoid vegetations are almost peculiar to childhood. 

Exciting Causes. — Though most people with acute rhinitis give exposure 
to cold as the exciting cause of their malady, probably on the ground of 
post hoc ergo propter hoc, exposure to cold alone, without some other ex- 
citing cause, is doubtless an overestimated source of the disease. In acute 
rhinitis, as in pneumonia, chilling of the body seems to act as a predisposi- 
tion to infection by lowering vitality, and it is likely that there is an 
infectious element in most cases of idioi^athic acute nasal catarrh, — an 
element called forth by conditions reducing the vital resistance of the 
individual. The relaxing effect of a hot bath, followed by gradual 
cooling of the body, is often succeeded by acute rhinitis, so that it is 



252 DISEASES OF THE NOSE AND NASOPHARYNX. 

the custom in bathing establishments to follow a hot bath by a cold 
shower. The sudden violent chilling of the skin thus produced acts 
as a vascular tonic, while gradual cooling off leads to mucous inflam- 
mations. 

Arctic voyagers assert that in the pure air of the polar regions, in 
spite of the great exposure to low temperatures, acute colds are almost 
unknown. Tliough clinical exi)erience encourages the belief that acute 
coryza is transferred from one person to another, and though the dis- 
ease in its general symptoms resembles an infectious one, a review of 
the literature to the present time shows that it has not been possible so 
far to transfer a common cold in the head from one person to another by 
direct inoculation. ^NTeither has it been proved that any one microbe is 
the specific cause of idiopathic coryza. Many bacteria are found, how- 
ever, on the nasal mucous surface in this disease, as the pneumococcus, 
the streiDtococcus, and the staphylococcus pyogenes albus and aureus. 
These bacteria can also be found on the healthy mucous membrane, and 
it is probable that increased virulence on their part and diminished 
tissue resistance due to lowered vitality cause them to excite inflamma- 
tion of the mucous membrane. 

Chemical Causes of Acute Ehinitis. — The well-known rhinitis that fol- 
lows the taking of potassium iodide is a tyi^e of these. Carbon diox- 
ide acting on the potassium iodide in the nasal secretions sets free the 
irritant iodine. Ipecac-dust will cause acute nasal catarrh, on account of 
the irritating effects of its alkaloid, emetine. Chlorine is another intense 
nasal irritant, as it forms hydrochloric acid on moist surfaces. Other 
chemicals capable of causing coryza by inhalation are nitric acid, am- 
monia, mercury, arsenic, phosphorus, and hydrofluoric acid. The bichro- 
mate salts are especially apt to excite nasal catarrh, and if their effect be 
long continued they may produce necrosis of cartilage and perforation 
of the septum. 

Mechanical Causes of Acute Bhinitis. — These are dust of all kinds, as 
coal-dust, wood-dust, flour- and tobacco-dust. Dust inhaled on a railroad 
journey will often cause coryza in those predisposed. 

Symptomatic Acute Ehinitis. — Here, in contradistinction to idio- 
pathic acute nasal catarrh, whose connection with bacterial infection is 
only suspected, there is a nasal catarrh occurring as a symptom of a 
general disease of undoubted microbic origin. First and commonest of 
these of late years is influenza, whose bacilli are present in the nasal dis- 
charges. Measles is at times accompanied by coryza of great intensity, 
as also is scarlet fever. W. J. Class has produced in swine a disease 
resembling scarlet fever by inoculation with a diplococcus obtained from 
scarlet fever patients. In a x^ei'sonal communication he states that he 
has found this organism on the mucous membrane of the nose of patients 
having scarlatinal rhinitis. Acute nasal catarrh is also found in typhoid 
fever, recurrent fever, pertussis, small-pox, and syphilis. The possibility 



ACUTE RHINITIS AXD HAY FEVER. 253 

of gonorrhoeal infection of the nasal mucous membrane is questioned, 
thougli the acute rhinitis of infants born of mothers with leucorrhcea — 
the form of i)urulent rhinitis called rhinitis blennorrhoica — is probably 
due to gonorrhoeal infection. Acute gonorrhoeal rhinitis in the adult is 
certainly very rare, considering the frequency of gonorrhoea. All cases 
of acute purulent nasal catarrhs have pyogenic organisms of some kind as 
their exciting cause. 

SymjJtoms. — There juslj be slight prodromal symptoms, headache, 
feverishness, vague pains throughout the body, though often the local 
signs are the first things to be noticed. At the commencement of acute 
rhinitis the nose feels dry and obstructed, this being soon followed by 
a burning, itching sensation that excites sneezing. The secretion, at first 
a scanty, clear mucus, soon changes to an abundant, thin, serous flow 
which macerates the epidermis at the nasal entrance and creates erythema 
of this and the upper lip, a condition apt to pass into eczema. In most 
cases of acute rhinitis the nasal passages soon become partially or totally 
occluded on account of accumulation of secretion and swelling of the 
turbinals. This swelling is apt to be intermittent, with times of almost 
perfect relief. Many people have only local discomfort as a result of 
coryza, while others have severe frontal headaches, sleej^lessness due to 
obstructed respiration, marked interference with miMital in'ocesses, and 
fever. The existence of this and the occasional presence of enlarged 
cervical glands show that at least a proportion of the cases of acute 
rhinitis are due to infection. Alteration of speech occurs, which may vary 
from a slight loss of the resonance of the voice to its complete deadening, 
due to absolute nasal obstruction, and in these cases articulation becomes 
defective. Partial deafness and tinnitus aurium, lachrymation, and con- 
junctival redness are found in a number of cases of the severer type. 
The swelling of the middle turbinals shuts off the olfactory region from 
the air- current, so that disturbances of smell and taste take place.. The 
secretion, at first thin and irritating, becomes thicker after two or three 
days, and changes to a whitish, yellowish, or greenish hue. The latter is 
due to altered blood-pigment, while the opacity is largely caused by 
epithelial debris. The continued mouth-breathing gives the tongue a 
dry and brown coating, and there is often loss of api3etite. 

Ehhioscopie Appearances. — The mucous membrane is usually red and 
congested in the severer types of the disease. In the milder ones 
the appearances may differ surprisingly little from the normal, so that 
the increased amount of secretion lying in the nasal passages is the only 
thing which seems to give basis to the patient's complaints. The swollen 
inferior turbinals may touch the septum, while a probe can be made to 
sink into the swelling as into an air-cushion. The middle turbinals 
commonly are of a paler hue and more transparent appearance than the 
lower, and may be so oedematous as entirely to shut off the olfactory 
region from the air-current. According to the stage of the disease, thin, 



254 DISEASES OF THE NOSE AND NASOPHABYNX. 

watery secretion or secretion of a thicker and more opaque character may 
be seen lying on the floor of the nose or filling the meatuses, at times 
reaching from septum to turbinal in sticky threads. Occasionally small 
hemorrhages occur beneath the mucous surface, producing dark stains, 
while sui)erficial epithelial erosions may be visible on the anterior part 
of the septum and lower turbinals. Fissures and rhagades can be seen 
on the nostrils, which may be encircled hy eczematous crusts, making 
the introduction of the nasal speculum very painful. 

A variety of acute rhinitis is that occurring in nursing infants, which 
exists either as a simple idiopathic rhinitis or in the graver form of acute 
purulent nasal catarrh. A third form of coryza peculiar to infants is the 
early syphilitic form, which will be considered under the heading of 
syphilis of the nose. 

The simple rhinitis of infants differs from that of adults in this, that 
if of a severe type it is a serious affection. A little swelling makes the 
narrow nasal passages of the infant im^^assable for air, and, as the child 
has not learned to breathe through the mouth, it oi^ens this only when 
dyspnoea actually forces it to, and closes it again after a few gasps until 
renewed dysiDuoea comi)els it to open it once more. Xursing and nutrition 
are also interfered with, and exhaustion and an atelectasis of the lungs have 
supervened in some cases. There is also a tendency for laryngitis and 
bronchitis to complicate coryza in infants. Blennorrhagic or purulent rhi- 
nitis is that variety in which the discharge is i^urely pus from the start : it 
is also commonest in infant life. The symptoms are all more severe than in 
idiopathic rhinitis, and emaciation is rapid and great. The external nose 
swells, the nostrils are closed by crusts, removal of whicli discloses a nose 
full of pus, either creamy or thin and ichorous. The mucous membrane 
may be highly inflamed and bleed or pale and anaemic. Purulent con- 
junctivitis, suppurating otitis media, and enlarged lymphatic glands often 
complicate the disease. In most of these cases the infection can be traced 
to a maternal leucorrhoea, the disease having been communicated at 
birth. 

Later in life, with the exception of gonorrhoeal rhinitis, occurrence of 
which has been denied by some, purulent forms of rhinitis accompany 
scarlet fever, measles, small-pox, and typhoid fever. All these forms are 
especially apt to lead to supi)urating otitis media. 

CompUcatmis of Acute Rhinitis. — The swollen and eczematous skin of 
the upper lip and nasal entrance may furnish the starting-point for ex- 
tensive facial eczema in children. Herpes labialis also occurs, and facial 
erysipelas often starts from the fissures on the edge of the nostrils. In 
ordinary colds the inflammation is apt to extend through the lachry- 
mal duct to the conjunctiva, causing slight conjunctivitis with lachryma- 
tion and photophobia ; but the purulent forms of nasal catarrh are the 
chief causes of suppuration of the lachrymal cyst and canal. 

The accessory sinuses may be involved in acute rhinitis, as has been 



ACUTE RHINITIS AND HAY FEVER. 255 

proved by post-mortem examinations by Zuckerkandl ; however, the 
mucous lining of these cavities usually returns to its normal condition 
when the nasal catarrh subsides. Involvement of the frontal sinuses 
probably is the cause of the severe frontal headaches accompanying some 
colds in the head, as the presence of pain and heaviness in the cheek is 
doubtless often due to acute catarrh of the antrum of Highmore. In 
cases of acute rhinitis with symptoms of this kind the globe and cheek 
may remain dark on transillumination, a procedure described with dis- 
eases of the accessory sinuses. Antrum disease, or that of the other ac- 
cessory sinuses complicating acute rhinitis, may become supi^urative and 
lasting; this is especially ai^t to occur after the rhinitis of influenza. 
Kuhnt thinks that suppuration of the sinuses is more apt to happen in 
those predisposed by the anatomical changes of chronic rhinitis. Severe 
colds and suppurative acute nasal catarrhs have been known to precede 
cerebrospinal meningitis, and it is surprising that this does not occur 
oftener, considering the direct lymphatic and venous connection between 
the nasal cavity and the subdural and subarachnoid spaces. Pain in the 
forehead and cheek may not be due to sinus disease, but to supraorbital 
and infraorbital neuralgias accompanying acute rhinitis. These can read- 
ily be accounted for when it is remembered that the first and second 
divisions of the fifth i)air of cranial nerves supply the nose with sensa- 
tion, and that their terminal fibres on the surface of the nasal mucous 
membrane are subjected to strong irritation in acute rhinitis. 

Acute rhinitis extending to the nasopharynx may cause enough swell- 
ing of its mucous membrane to mechanicall}' close the Eustachian orifice, 
thus stopping the ventilation of the middle ear. This is especiallj^ apt 
to occur in children or young people with considerable adenoid tissue in 
the nasopharynx, not enough to obstruct nasal respiration, but suffi- 
cient to cause deafness with each acute cold. Acute rhinitis may also be 
the cause of middle-ear catarrh, at times of a sui)i)urative character, with 
perforation of the membrana tymi^ani. The infectious elements of the 
rhinitis flow back into the nasopharynx, and are readily driven into the 
Eustachian tubes by means of the blasts of air forced up them in blowing 
the nose. Luschka's tonsil, the faucial tonsils, the larj-nx, and the trachea 
may also be involved in inflammation by the extension of an acute rhi- 
nitis, and follicular tonsillitis occasionally follows the rhinitis due to 
intranasal operations. 

Diagnosis. — Acute rhinitis is not likely to be confounded with any 
other affection, but it is necessary to ascertain what variety of the disease 
is present and its cause. Thus, the coryza of measles or that due to 
scarlet fever is to be distinguished by the symptoms characteristic of 
those diseases. In the coryza of influenza the prevalence of epidemic 
influenza and the high fever found with the disease, with its severe general 
symptoms, help to differentiate it from the idiopathic variety. 

The purulent coryza of infants can be distinguished from the simple 



256 DISEASES OF THE NOSE AXD NASOPHARYNX. 

form by the character of the discharge and the long duration and severity 
of the symptoms, and inspection will make the diagnosis of membranous 
rhinitis clear. In early syphilitic rhinitis in infants there is less dis- 
charge than in the common variety and a great tendency to formation 
of crusts. Syphilitic eruptions and the characteristic ax)pearance of the 
syphilitic infant are aids to diagnosis. Unilateral x^urulent discharge 
should lead the surgeon to suspect the presence of foreign bodies or sinus 
disease. 

Prognosis. — The prognosis of acute rhinitis is largely influenced by its 
cause. Those cases due to virulent infections may lead to suppuration 
of the sinuses or of the middle ear, and in rare cases to meningitis. In 
infants the difficulty in breathing, the interference with nursing, and the 
tendency of the catarrh to invade the larynx and bronchi make the 
prognosis serious. Chronic suppuration of the tear-sac may remain as a 
sequela. 

In children the lymphatic collection in the nasopharynx called 
Luschka's tonsil, lying as it does in the course of the lymph-stream 
from the nose to the pharynx, forms a place for the deposit of infectious 
elements derived from the inflamed nasal mucous membrane, and it is 
therefore not remarkable that rhinitis in children is ax^t to lead to en- 
largement of Luschka's tonsil. In adults repeated attacks of the disease 
often result in intumescent or hypertrophic rhinitis. The duration of 
acute rhinitis is commonly from three days to three weeks, though some- 
times it lasts but a few hours, the stage of dryness ending in from two 
to three hours and that of free discharge in from two to three days. The 
third x>eriod is of very variable duration, and recurrence of the malady 
after apparent recovery is not uncommon. 

Catarrhal otitis media causing in some cases sclerosis of the structures 
of the middle ear and permanent impairment of hearing may follow 
acute rhinitis, and the origin of nasal mucous ]3olypi has been traced to 
repeated attacks of the disease. Acute nasal catarrh in children, with 
cracks and eczematous surfaces on the nostrils and upper lip and epi- 
thelial erosions in the nasal i^assages, may form a source of entrance for 
the tubercle bacillus into the lymphatic system. The bacilli rarely lodge 
in the adenoid tissue of the nasopharynx, but more often infect the cervi- 
cal lymph-glands, forming in them a source from which in later years 
infection of the pulmonary ajDices may take place. Thus the scrofulous 
state may originate in acute rhinitis in childhood, the chronic nasal 
catarrh, otorrhcea, eczemas, and hyj^erplastic lymph-glands following it. 

Treatment — Prophylaxis. — The best preventive of acute rhinitis is 
physical vigor. Out-of-door exercise, proper attention to nutrition and 
maintenance of the body-weight at its normal standard, cold shower- 
baths, gymnastics, with avoidance of excessive clothing and overheated 
houses, — in fact, that careful attention to general health that makes the 
individual more resistant to depressing influences or infections is the 



ACUTE RHINITIS AND HAY FEVER. 257 

best means of a general character for the avoidance of attacks of acute 
rhinitis. Notwithstanding this, most people have their quota of colds in 
the head, and individual predisposition will make some of the most 
vigorous frequent sufferers. Local prophylaxis includes the removal of 
such obstructions as adenoid vegetations, septal deformities, hj^pertrophic 
rhinitis, and polj^i^i. It is not usuallj' possible for those exposed habitu- 
ally by reason of their occupations to the chemical and mechanical causes 
of acute rhinitis to avoid these, but for those temporarily under their 
influence it is well to place a light piece of cotton in tlie nostrils, not 
enough to stop respiration, but sufficient to catch foreign particles. 
Where irritating gases are present efficient ventilation is indispensable. 
Eespirators — mechanical contrivances intended to act as dust-filters — 
are not practicable, as most i^eople cannot be induced to wear them on 
account of the disfigurement they occasion. Those who use them find 
decided benefit. Manj^ methods of treatment exist intended to cut short 
a rhinitis at its beginning, — the so-called abortive treatment. It is ob- 
viously as impossible to stop the symptomatic rhinitides at their inception 
as it is to abort the coryza of measles or scarlatina or influenza. The 
varieties due to chemical or mechanical agents subside with the re- 
moval of the cause. One cannot expect to bring the acute purulent 
catarrhs due to pus microbes to a speedy end by general abortive meas- 
ures. This leaves only idiopathic acute rhinitis as suitable for this 
method of treatment. Considering that acute coryza is doubtless also 
often due to local infection from the microbes mentioned in a previous 
part of this article, and that it is of very variable duration, it is diffi- 
cult to tell how often the speedy termination of a common cold is due 
to abortive measures. Certainlj' the vital powers of the patient and his 
resistance to disease at the time he acquires the cold have much to do 
with its severity and duration. To check the disease diaphoretics have 
been in use for a long time. Their effect is to lessen the fluids of the 
body, and this accounts for their reputation as aborters of the ailment. 
For diaphoresis Turkish baths are efficient, though they are sui^posed to 
lead to increase of the malady if there be incautious exposure following 
them. Pilocarpine and other diaphoretics have an effect similar to the 
Turkish bath, anxl diuretics and cathartics may expedite the cure. 
These means should be used only when the patient can stay indoors, and 
it is well for him to limit his fluid-supply in order to prolong the dia- 
phoretic or diuretic beneficial influence. As a course of treatment the 
following can be recommended : first, a comparatively large dose of 
quinine or of nux vomica and the application to the nares of a one or 
two per cent, solution of cocaine in water or, better still, in oil, or the 
insufflation of a powder of three or four per cent, of cocaine. These 
powders should not be used more than three or four times a day in either 
naris, and not more than from half a grain to a grain and a half of the 
mixture should be used each time. The powder which seems most use- 

17 



258 DISEASES OF THE NOSE AND NASOPHARYNX. 

ful contains cocaine three per cent., sodium bicarbonate and sodium bi- 
borate each one and one-half per cent. , iodol twenty-five per cent. , light 
magnesium carbonate one per cent., and sugar of milk enough to make 
up the whole amount ; or this powder may be varied by leaving out the 
iodol, or by adding one per cent, of alumnol or five or ten per cent, of 
boric acid. I^ot more than a hundred grains of any of these mixtures 
containing cocaine should be given to the patient at once, and he should 
never be given a prescription that may be repeated. The tendency is to 
prescribe large quantities of cocaine to give relief in acute rhinitis, when 
as weak a solution as one grain of cocaine to the ounce of equal parts of 
a saturated solution of boric acid and water will reduce the obstructing 
swelling of the nasal mucous membrane enough to give the patient com- 
fortable breathing in an ordinary case of coryza. People differ greatly 
in their susceptibility to the unpleasant effects of cocaine, palpitation 
and nervousness occasionally following even moderate doses. 

In some cases even better results than from cocaine can be obtained 
by substituting for it an aqueous extract of the adrenal glands described 
under chronic rhinitis. In the latter case it is well to use also a spray 
of oleum petrolatum album three or four times daily. Occasionally 

Fig. 102. 



Freer's nasal irrigating tube. 

patients are seen in whom oily sprays of any kind aggravate the disease, 
and in such subjects a solution of boric acid is apt to be most soothing. 
Should the disease run a longer course, the cocaine may be continued in 
small quantities three or four times a day. The patient may be given 
with advantage, four or five times daily, small doses of cannabis indica 
and hyoscyamus, with medium doses of camphor and quinine, or quinine, 
and phenacetin, or quinine and monobromated camphor. The salicylates 
salol and salipyrin have been recommended as remedies capable of 
limiting the duration and improving the symptoms of acute rhinitis, and 
they seem to be of benefit in some cases. 

Ehinitis blennorrhoica, or purulent rhinitis, whether occurring in 
adults or children, requires the removal of the discharge from the nostrils, 
if possible, by means of irrigations, as sprays are not sufficient in these 
cases to effect this if the secretions be thick. For adults and children 
over eight years of age a hard- rubber Eustachian catheter, closed at one 
end and drilled with three small holes of pin-hole size near the closed 
end (these holes can be made with a hot needle), is a safe and efficient 
irrigant 5 or the catheter, being heated and straightened before use, can 
be passed back and forth in the nostril into the nasopharynx, while a 
stream of water flows in tiny jets from the little holes and washes the 



ACUTE RHIXITIS AXD HAY FEVER. 259 

nasal cavity with sufficient force to cleanse it of the pus which is often 
present in dense masses. The sui)ply of fluid is furnished by a fountain 
syringe that is connected with the catheter by the usual hard-rubber 
mount. The danger of large streams from the nasal douche or syringe 
forcing fluid into the middle ear is well known, and is avoided by this 
instrument; which can safeh^ be trusted to the patient. A good antisep- 
tic wash to use in these cases is potassium permanganate, one-eighth of 
a grain to the ounce of water. 

In i)urulent rhinitis it is very hard to cleanse the noses of children 
from two to eight 3'ears old, as often even a sj^ray terrifies them and 
cannot be used. Frequently the surgeon is limited to dropi^ing a few 
drops of oleum petrolatum album into their nostrils to dissolve dried 
secretions, and to painting the upper lip and inside of the nostrils with 
vaseline. This at least j)rotects these parts from the discharge and pre- 
vents the formation of crusts. In infants in whom there is extensive 
secretion, as they can easily be held still, the nose is best cleansed by 
springing with a warm alkaline solution. The washing must be per- 
formed very carefully, and it must not be forgotten that often even very 
mild solutions are irritating to the nares and give the child pain. When- 
ever it is deemed necessary to syringe the nares in a child, it should be 
placed upon its face and the warm solution introduced slowly, so that it 
may run out again from the oj)posite nostril and not be drawn into the 
larynx. Larger children under eight years will usually not tolerate 
syringing, and oily sprays with small doses of quinine form the best treat- 
ment. For nursing infants whose nostrils are entirely occluded it has 
been recommended to ]3ass small drainage-tubes through the nostrils into 
the nasopharynx, so that the children can breathe through these. Feeding 
with a spoon is necessary when the child cannot nurse. An effective 
plan for the introduction of oil into the nostrils for the solution of dried 
secretions is the use of a common oiler, or oil- can of the type used by ma- 
chinists. It should be filled with thick vaseline oil, which can be dropped 
into the nares while the patient's head is thrown back. It very effectu- 
ally takes the jDlace of the more costly atomizer and does not get out of 
order. 

HAY FEVEE. 

Synonymes. — Hay asthma, rose cold, June cold, autumnal catarrh, rhinitis 
hyjDerfesthetica, catarrhus cestivus, coryza vasomotoria. 

Hay fever is an acute catarrhal irritation or vasomotor neurosis of the 
conjunctiva, nasal mucous surface, and rest of the respiratory tract. It 
occurs periodically, and is characterized generally by profuse discharge, 
attacks of nasal occlusion due to swelling of the turbiuals, and asthmatic 
attacks. In America the aftection usually begins in early August and 
lasts until the end of September, although a considerable number of cases 



260 DISEASES OF THE NOSE AND NASOPHARYNX. 

are seen in May, June, and July. Men are rather more often affected than 
women^ and the disorder generally occurs before middle age, though it 
may afflict all ages, even little children. It is a disease of educated ])eople 
mostly and of city dwellers, while the laboring class is generally spared. 
Hay fever is but a well-marked type of coryza vasomotoria, or those 
acute catarrhs of the nose and of the respiratory tract originating in 
chemical or mechanical irritation of the nasal mucous surface with reflex 
vasomotor paresis and hypersecretion, so that similar states can be pro- 
duced by any irritation of the nasal mucous membrane at any time of 
the year. 

Etiology. — Sufferers from hay fever are generally, but by no means 
always, nervous people, as it will attack very robust individuals with 
stable nervous systems, while, on the other hand, the majority of even 
very nervous people do not acquire the disease. It is not known why 
one individual should respond to irritation of the distribution of the 
fifth nerve in the nose with a vasomotor relaxation of the nasal erectile 
tissue and another remain unaffected. Intumescent rhinitis ^predisposes, 
yet many with this ailment do not have hay fever. The exciting cause 
of the attack is commonly the inhalation of the pollen of Ambrosia 
artemisicefoUa, known also as Eoman wormwood, ragweed, or hogweed, 
or of SoUdago odora, known commonly as golden-rod. This is the 
cause of hay fever proper 5 but a similar state, known as coryza vaso- 
motoria, of a transient and less obstinate nature^ with swelling and free 
watery secretion, may be caused by dust and smoke, especially in rail- 
way travel, by the emanations of roses and other fragrant plants, and by 
the pollen of certain grasses, as wheat, barley, oats, rye, or even Indian 
corn. It may also be excited by the dust of ipecac, salicylic acid, ben- 
zoic acid, and lycopodium, and sometimes is brought on by exposure to 
heat or light, or by overfatigue. 

J. F. Barnhill thinks that areas made oversensitive by the pressure 
of septal exostoses or deflections, and polypi or other conditions bringing 
mucous surfaces in contact in the nasal cavity, are of great moment in 
predisposing to hay fever. Eemoval of nasal abnormalities, however, 
unfortunately, does not usually prevent the occurrence of the disease, 
though it may mitigate its severity. The so-called uric acid diathesis 
is one of the alleged predisposing causes of hay fever, but as ui-ic acid 
has been proved to be a harmless substance, it can hardly create any but 
a hypothetical diathesis ; the state called gout, however, is certainly a 
predisposing cause. 

Fathology. — The anatomical conditions do not differ from those de- 
scribed under acute rhinitis. The catarrhal irritation is not a true in- 
flammatory process, however, as in the infectious varieties of acute 
rhinitis, but rather an abnormal sensitiveness of the vasomotor reflex arc 
to irritations that ordinarily cause no response. The condition is, there- 
fore, a neurosis characterized by increased activity of the function of 



ACUTE RHINITIS AXD HAY FEVER. 261 

secretion and by acute hypersemia of the mucous surface with, swelling 
chiefly of the turbinals, which frequently close up one or both nasal 
fossse, and show the usual variations of intumescence described with acute 
rhinitis, at one time leaving the nose almost free for respiration, at others 
making this quite impossible. The irritation often involves not only the 
nasal cavity but the larynx, conjunctiva, and bronchial tubes as well. 

Sym2)toms. — So regular is the disease in its annual recurrence that 
most patients aj^proximately know the date when they will begin to 
suffer. The disease occurs in two forms, the catarrhal and the asthmatic. 
In the catarrhal form the irritation is confined to the nares. conjunctiva, 
and pharynx, while the asthmatic usually follows the catarrhal variety 
in from two to three weeks, or may exist independently of any nasal 
symptoms, or if treatment prevent the occurrence of the nasal inflam- 
mation. The asthmatic form is therefore usually due to direct irritation 
of the bronchi rather than to nasal reflex. It is going too far, however, 
to deny absolutely the existence of nasal reflex asthma. 

Hay fever usually begins suddenly in the form of a severe acute rhi- 
nitis. Tickling and burning in the nose are felt, while violent sneezing 
heralds the disease. The mucous membrane swells rapidly, stopping up 
the nares, while an abundant thin serous discharge occurs. The eyes 
smart and stream with tears. The conjunctiva is swollen and patients 
blink in the light. The lids become puffy, and the usual neuralgic pains 
accompanying rhinitis occur, — aching in the orbit, occipital neuralgia, 
and pain in the nasal bridge and forehead. The lips and nostrils are raw 
and excoriated. Affections of the ear are unusual complications, but 
partial deafness may occur. The sense of smell is generallj^ much im- 
paired or lost. 

The attack generally lasts from six weeks to two months, but some 
fortunate ones recover after a few days. Such persistent suffering for 
weeks as is entailed bj' the average attack of hay fever of course tells on 
the general health, and as true inflammation due to secondary infection 
succeeds the irritative hypersemia, fever may occur, but does not belong 
to the ordinary symptoms of hay fever. Inspection shows nothing differ- 
ing from the conditions described under acute rhinitis, except that the 
mucous surface is usually paler, and the discharge watery rather than 
mucopurulent during the greater part of the disease. Towards the 
end, however, it becomes oi)aque through the admixture of leucocytes. 
Probing discovers areas of extreme sensibility, and these should be noted 
for future treatment. Though the attack generally ends suddenly, it may 
gradually fade away. 

The asthmatic form of hay fever does not differ materially from ordi- 
nary asthma. It presents itself in paroxysms of dj'spnoea with dry rales. 
There is often much annoying cough. The asthmatic attacks happen 
usually in the daytime, and in this hay asthma differs from the ordinary. 
There is danger that those afflicted with hay asthma may develop into 



262 DISEASES OF THE NOSE AND NASOPHARYNX. 

confirmed asthmatics with paroxysms at all times of the year. The 
asthma of hay fever is apt to be prolonged over many weeks^ and is of 
extremely persistent nature. 

Diagnosis. — A first attack is hard to tell from a severe coryza, but the 
history of repeated attacks occurring near the same date, the sensitive 
areas in the nose, the obstinacy of the disease and the season at which 
it occurs, together with its general prevalence, make the diagnosis usu- 
ally easy. In fact, the patient has generally not only diagnosed his case, 
but has made enough therapeutic attempts to discourage him. 

Frognosis. — From thirty to fortj" per cent, of the patients can be 
cured by the proper use of the galvano- cautery in the interval ; the rest 
of the hay fever sufferers will at least have the severity of the attack 
mitigated by treatment ; but many, in spite of everything, must expect to 
suffer more or less, and large numbers look to change of climate as the 
only relief 

Treatment. — Change of climate will nearly or entirely dispel the 
symptoms, provided it be to a locality with air free from pollen. In 
America the favorable localities are N^orthern Michigan or Wisconsin or 
the north shore of Lake Huron or Lake Superior. The White Moun- 
tains, in some cases high altitudes in the Eocky Mountains, and the 
sea-shore will give immunity to many, ^o locality will be found equally 
beneficial for all individuals, and some will suffer severely where others 
have complete relief. 

The general treatment of hay fever includes all those measures that 
will diminish the irritability of the nervous system. If impaired, its 
nutrition must be brought to a proper level by sufficient and judicious 
eating. The body-weight must, if possible, be brought to its normal state. 
As a local application to the Schneiderian mucous membrane, a spray of 
a saturated solution of boric acid will sometimes be found very grateful. 
In some instances it is well to make this solution in camphor- water ; in 
others it will be necessary to add to it small quantities of atropine, mor- 
phine, or cocaine. The latter remedy gives more immediate relief than 
any other, but, unfortunately, its continued use is frequently followed by 
most serious consequences. The aqueous extract of the adrenal glands 
recommended in the treatment of chronic rhinitis has given marvellous 
relief in some cases. With some patients oily sprays will be found more 
beneficial. For this purj^ose a most excellent combination is that of 
thymol one-third grain, oil of cloves three minims, and oleum petrolatum 
album one drachm, to which in some cases a small amount (not more 
than one-half per cent.) of the alkaloid cocaine may be added. The 
strength of this solution may be slightly increased in some cases with 
advantage, but care should be taken not to make it irritating. A similar 
spray used five or six times a day will sometimes prevent the paroxysms 
of this disease. A powder containing three or four per cent, of cocaine 
hydrochlorate will be found more convenient for general application. In 



ACUTE RHINITIS AND HAY FEVER. 263 

whatever way cocaine is employed, tlie patient should not use more than 
one-third of a grain daily, and this should not be long continued. Be- 
cause of the temporary relief afforded, sufferers are very apt to use this 
remedy to excess, therefore physicians should never give written x^re- 
scriptions containing it, and should insist upon knowing exactly how 
much is being used. 

Eixe asserts that he has aborted hay asthma with large doses of terpin 
hydrate, ten grains every three or four hours, two weeks before the attack 
begins, and during this once in two hours. When the attack of hay 
fever has developed, but little can be done for it beyond i)alliation, but 
in the interval operative measures tend to mitigate or actuallj^ l)revent 
the outbreak of the disease. All nasal abnormalities of consequence, as 
septal spurs, deflections, nasal mucous polypi, hypertrophic or intumes- 
cent rhinitis, should be treated as described under their headings. The 
most beneficial results are obtained by cauterizing the sensitive areas in 
a superficial manner. 

The nasal cavity should first be thoroughly examined with a flat 
probe, the various parts being gently touched and the sensitive spots 
marked upon a diagram representing the two surfaces of the nares. A 
solution of cocaine is then applied by means of a small pledget of ab- 
sorbent cotton wound on the end of a flat nasal applicator. The pledget 
saturated with the solution is carried back to the j^osterior i)art of the 
naris, and as it is brought forward is rubbed gently over every part 
of the mucous membrane to be anaesthetized. This occupies about thirty 
seconds. A minute later the application is reiDeated with a fresh 
pledget. From two to four such applications are generally sufficient. 
The cauterization maj^ commonly be performed without pain as soon as 
the patient ceases to feel the probe rubbed lightly over the surface, even 
though i^ressure may still be felt. 

Before cauterizing the nasal fossae are to be si)rayed with fluid petro- 
latum, as the oil}^ lubricant makes the manii^ulation of the electrode 
in the nose easier. A flat electrode is to be used, preferably guarded in 
narrow nasal passages. This is heated to a red, not white, heat, and 
rubbed over a spot in the sensitive area from three- eighths to five-eighths 
of an inch in diameter until this appears seared and white. The object 
is not to burn beneath the epithelial layer, simply to blister. The next 
cauterization should follow in a week or ten days, preferably in the 
other nostril, and cauterization continued until the j)robe detects no 
more sensitive spots. After the cauterization the patient may be given a 
four per cent, powder of cocaine, which may be insufflated into the nares 
once in from three to five hours for the following three or four days. To- 
gether with this it is well to give an oily spray similar to that already 
recommended. From fifteen to thirty treatments are generally necessary 
to cover all of the diseased surface. The following year a few spots may 
be found still sensitive which were overlooked previously or not burned 



264 DISEASES OF THE NOSE AND NASOPHARYNX. 

deeply enough ; or possibly these may result from a new development of 
the disease. The above treatment is inadmissible during the attack, as 
it would add to its violence. It is best instituted in the warm season, a 
month or two before the expected onset. By this method from thirty to 
forty per cent, of cases of hay fever may be cured, about twenty-five per 
cent, may be greatly benefited, and the remainder will usually obtain 
sufficient relief from the nasal symptoms to compensate for the discomfort 
experienced during the treatment. The asthmatic attacks are to be treated 
as are those of ordinary asthma, but to avoid the possibility of the 
patient's becoming a confirmed asthmatic it is well that he should seek a 
climate where he will not suffer from hay fever before the usual time of 
its development. 



CHAP TEE IV. 

EPISTAXIS AND XASAL AFFECTIONS IX ACUTE IXFECTIOUS DIS- 
EASES. 

EPISTAXIS. 

Synonymes. — Xose-bleed, hemorrhea nariiim. 

Ix epistaxis there occurs bleeding from the anterior or posterior nares, 
the hemorrhage originating in the nasal cavity or accessory sinuses. 

Etiology. — Predisposition to epistaxis is caused by changes in the com- 
position of the blood, as in ansemia, leukaemia, and scurvy ; also acute 
infectious diseases predispose to nose-bleed and may be ushered in by it. 
Changes in the vessel-walls, as in arteriosclerosis, and probably also in 
purpura and hiemophilia. lead to epistaxis. Active hypeniemia of the 
nasal blood-vessels during violent exertion, and that due to exposure of 
the head to the hot sun, will increase liability' to nose-bleed. Ei3istaxis 
is also a symptom of chronic Bright' s disease, together with the usual 
retinal, cerebral, and other hemorrhages. Vicarious nose-bleed may take 
the place of the menses, or represent them in j^regnancy and (rarely) in 
the menopause. 

Passive hyperiemia due to valvular heart disease, liver disease, hea^'y 
lifting, straining, or coughing is not an uncommon cause, as also is 
obstruction of the circulation in the lungs due to emphysema. Dimin- 
ished atmospheric i^ressure — as, for instance, that due to high altitudes — 
will cause nose-bleed. The fatty degeneration of the vessel-walls due to 
acute or chronic i^hosphorus- and belladonna-poisoning, iodism, potas- 
sium chlorate and iodoform-poisoning, and snake-bites are among the 
toxic causes of nose-bleed. 

Local Causes. — Ehinitis atrophicans will cause epistaxis when scabs 
are forcibly separated from their base, and foreign bodies, if sharp 
enough to wound the mucous membrane, produce bleeding from the nose. 
Fracture of the base of the skull is apt to be associated with nasal hem- 
orrhage, together with bleeding from the ears and subconjunctival 
ecchymosis. Contusion of the nose is a well-known cause. Bleeding 
during intranasal operations is nsually free and annoying to the operator, 
on account of its rapidly obscuring the field of vision. A source of 
serious hemorrhage is found at times in deep syphilitic ulcers, if an 
artery be opened by them. Some forms of nasal tumors, especially the 
malignant ones or fibrous polypi, may be the source of profuse sponta- 
neous rhinohemorrhea. 

265 



266 DISEASES OF THE NOSE AND NASOPHARYNX. 

Pathology. — As epistaxis is only a symptom of many diseases, local 
and general, the pathological findings will belong to these. There is one 
condition, however, that is so often found that it may be said to be 
peculiar to epistaxis, — viz., a small bleeding-point, erosion, or little 
ulcer found on the anterior part of the septum, where it can easily be 
reached by the finger-nail, injury of the mucous surface by the finger-nail 
being often the cause of this condition. The hemorrhage may take place 
from unusually thin-walled, dilated vessels. Infection of these erosions 
with pathogenic germs may cause these little ulcers to penetrate to the 
perichondrium, causing perichondritis, with local death of the cartilage 
and perforations of the cartilaginous septum often as large as three- 
quarters of an inch in diameter. These do not close, but leave perma- 
nent defects after their borders have healed. 

Symptoms. — In plethoric individuals, or where there is vicarious nose- 
bleed, a feeling of fulness in the head with a sense of intranasal dis- 
tention, dizziness, and tinnitus may precede the epistaxis, while these 
symptoms may be relieved by its occurrence, the amount of blood vary- 
ing from a few drops to a quart or more. It may drop from the nose or 
run in a little stream, or if epistaxis occur while the patient is lying on 
his back, the blood may flow backward into the pharynx and larynx 
and be coughed up. The blood generally flows from one nostril, but 
if this be blocked, it may pass around behind the septum and flow from 
the other one. A large quantity of blood may be lost within a few hours, 
and the bleeding may continue for several days. When the bleeding is 
excessive, syncope is liable to occur, and may prove fatal. When epi- 
staxis occurs frequently or continues for several days, serious anaemia 
may result. 

Examination of the nose in ordinary cases, when the bleeding has 
ceased, will usually show the erosion, or bleeding-point, if aided by 
friction with a swab of cotton on the septum. In some cases, however, 
in which the surgeon is consulted concerning habitual nose-bleed, he is 
unable to detect any place which might be a likely source of the bleeding. 
During the bleeding, wiping away the blood with tampons, if it do not 
flow too freely, will disclose its source, but often the blood fills the nostrils 
too rapidly to make an accurate inspection possible. 

Diagnosis. — In order to distinguish simple ei)istaxis from bleeding 
neoiDlasms or ulcers careful inspection is needed. Blood flowing from 
the nostrils may have its source in hsematemesis or haemoptysis. On the 
other hand, in patients lying on the back, nose-bleed may exist as a 
concealed hemorrhage, especially if they be in a stupor, the blood being 
swallowed and later vomited. The blood in these cases may be passed 
from the bowels as a tarry stool. In other cases the blood is coughed up, 
making diagnosis from haemoptysis difficult. The usual source of the 
bleeding as mentioned is from the thin-walled, dilated vessels of the 
anterior part of the septum. Blood may, however, flow from any other 



EPISTAXIS AND XASAL AFFECTIONS IX ACUTE INFECTIOUS DISEASES. 267 

part of the nasal cavity, and the inferior turbinal is, next to the septnm, 
its most likely source. 

Frognosis. — Ordinary nose-bleed seldoni lasts beyond fifteen minutes, 
though in children it may be of long duration, but is rarely dangerous. 
Those forms of epistaxis accompanying degeneration of the vessel- walls 
in old people, or in chronic nei^hritis, not only indicate a liability to 
rupture of more im^^ortant vessels, — as, for instance, those of the brain 
or retina, — but the hemorrhage itself may be fatal. 

Operations on subjects with degenerated arteries are liable to be fol- 
lowed by secondary hemorrhage, which may be profuse even after so 
slight an operation as the removal of a mucous polyi)us from the nose. 

JSTasal hemorrhages frequently recurring and lasting several days at 
a time, unless j)roperly treated, cause dangerous anaemia, and many, 
therefore, terminate fatally. In low forms of fever and in diphtheria 
epistaxis is a grave symptom. On the other hand, in malarial fever, in 
plethora, or in congestive conditions of the brain the bleeding is some- 
times beneficial. 

Treatment. — Ordinary attacks of nose-bleed need no treatment, as they 
soon cease spontaneously. They can be cut short b}^ cold applications to 
the external nose and nape of the neck or by applications of hot water. 
The position assumed by the patient is usualh^ a fault}" one, as he bends 
forward over some vessel to catch the blood. This produces venous con- 
gestion of the head and adds to the flow. The patient should sit erect, 
or with his head thrown backward, while by taking deep inspirations 
through the nose he withdraws the blood from the veins into the capil- 
laries of the lungs. This measure alone will often suf&ce to stop nose- 
bleed. As in most instances the blood flows from a small point on the 
cartilaginous septum, it is easy to check it by continuous compression of 
the alse nasi for ten or fifteen minutes or by direct pressure of the finger 
upon the sej^tum. Compression of the facial artery is also recommended. 
Should the bleeding continue unduly and not yield to simi^le means, 
local treatment is needed. 

Those at all familiar with rhinoscoi)y and the use of instruments in 
the nose will j^refer to control the hemorrhage at once by applying 
tampons rather than to resort to irritating and uncertain styptic powders 
and spraj'S, which are liable not to reach the bleeding surface at all in a 
nasal fossa obstructed with clots and constantly filling with blood. Pow- 
dered alum and tannin have been applied, but the former is the source 
of great pain Avhen in contact with the mucous membrane, while the lat- 
ter is somewhat less irritating. A spray of tannin, ten grains to the 
ounce of water, is the most useful of these means, but small i^ieces 
of ice dropped into the nares may stop the bleeding. A spray of 
adrenals is the most efiective local application. If the hemorrhage be 
arrested h\ these local ai^plications. there is no surety that it will not 
return when the surgeon is far away and unable to be of assistance, while 



268 DISEASES OF THE NOSE AND NASOPHARYNX. 

a properly applied tampon is an insurance against return of the bleeding^ 
at least until its removal. The best material for tampons is absorbent 
lint cut into strips one-half an inch wide and from one to three feet in 
length, according to the amount of space to be filled. The strips are 
to be thoroughly impregnated with iodol or bismuth subnitrate, which 
will keep them aseptic for days. Absorbent cotton is a far inferior 
material, as pieces of it are apt to get lost in the nasal cavity. It has 
not the virtue of swelling which the lint has, and which in a short time 
doubles the volume of this material, thus exerting pressure, while, being 
in strips, none of the lint can get lost in the nose, and it can be with- 
drawn in one piece. The cotton not only does not swell, but loses elas- 
ticity and bulk. Previous to plugging a four per cent, solution of cocaine 
is to be applied with a swab to the parts against which the lint will im- 
pinge. A spray will not penetrate the blood, but a swab will succeed in 
rubbing a certain amount of cocaine into the mucous surface, this drug 
having the desirable effect of limiting and sometimes checking the hem- 
orrhage, making the nasal fossa more roomy and the operation less pain- 
ful. Instead of bismuth or iodol, iodoform and boric acid can be used to 
impregnate the lint. 

The simplest mode of tamponing is that used for the common form of 
epistaxis, in which the blood flows from the anterior part of the septum. 
Here it is merely necessary to plug the nasal fossa as far back as the 
middle of the lower turbinal. In other cases, in which the bleeding 
comes from the posterior parts of the nasal cavity, the whole nasal fossa 
must be filled with lint. To introduce this into the nose, the end of the 
strip is to be seized with the blades of the nasal scissors, or with a pair 
of nasal dressing forceiDS with small blades which are not serrated, but 
smooth on their inner surface. If serrated, the blades pull out the lint 
again as soon as they are withdrawn. The lint is to be introduced a little 
fold at a time, so that it can be apx^lied evenly. If too much be seized at 
once it will form a bunch that will lodge in the nasal passages and obstruct 
the way back. After the first folds have found a lodgement the rest of the 
strij) enters easily. To pack the anterior part of the nose, the end of 
the strip must be passed up between the middle turbinal and septum, 
while the following folds must fill the nasal fossa from above down. If 
it be desired to pack the whole naris, the end of the lint strip must be 
passed back to the end of the lower turbinal, but not into the naso- 
pharynx, as in this situation it will create a constant desire to hawk. 
When the nasal passages are verj^ roomy and the plug shows a tendency 
to slip back into the nasopharynx, it is well to attach three or four strong 
threads about two inches apart to the end first introduced. This end is 
then passed through the naris into the nasopharynx, the free ends of the 
thread being left hanging from the nostril. The strip is then rapidly 
pushed in until the posterior part of the cavity is full, after which the 
threads are drawn upon so as to pack the gauze firmly into the posterior 



EPISTAXIS AND NASAL AFFECTIONS IN ACUTE INFECTIOUS DISEASES. 269 

naris. The whole cavity is then filled with the strip of gauze, any re- 
maining portion being cut off. This method is suf&cient to stoj) the 
hemorrhage, even in the most severe cases, and will enable one with even 
moderate skill to spare his patient the dangers and torture of plugging 
the posterior nares. For a strong styptic effect the strij) can be soaked 
with a syrupy mixture of tannic acid and water to which a little car- 
bolic acid and glycerin have been added. This ai^plication causes irri- 
tation and smarting, and can ordinarily be dispensed with, as the bismuth 
or iodol usually suffices as a styj)tic. Though plugging of the j)Osterior 
nares has long been practised for checking obstinate epistaxis, it may be 
regarded as a relic of the past, and will hardly be emj^loyed by a rhi- 
nologist. It is commonly i)erformed with the aid of Bellocq's canula, 
by drawing through the nose, from the throat, a strong string, to which 
is attached a plug of cotton or lint of sufficient size to fill the i)Osterior 
nares. 

Ability to prevent recurrence of ei^istaxis will depend on the power 
to remove the cause. The erosions on the septum often bleed, merely 
because thin scabs which cover them are torn away by the finger or 
blast of air in blowing the nose. These raw places will heal if the secre- 
tions be kept from drying and scabbing by means of ointments like one 
of equal parts of lanolin and vaseline with two per cent, of salicylic acid. 
Even if the erosion become a small ulcer, it will often heal under this 
mild protecting application, which dissolves the scabs beneath which the 
pent-up secretions cause the ulcer to spread. If the erosion be slow in 
healing, it can be stimulated by touching it Avith silver nitrate, sixty 
grains to the ounce of distilled water. If the source of the bleeding be 
from small dilated vessels, it is best to sear these with the galvauo- cautery 
heated to a light red. This may succeed in preventing recurrence of the 
nose-bleed after the first treatment, or perhaps will need to be repeated 
once or twice. It is, without question, the best treatment for this con- 
dition. 

NASAL AFFECTIONS IN ACUTE INFECTIOUS DISEASES. 

The nasal cavity is the seat of pathological changes in many acute 
general affections, the chief of which are measles, scarlatina, typhoid 
fever, influenza, and small-pox. 

Ileasles. — In measles acute catarrhal rhinitis is an almost invariable 
and prominent sym^^tom, and i^recedes and accompanies the exanthema. 
It may be of a severe grade, but does not differ ordinarily from simj^le 
acute rhinitis. Illumination by sunlight will show the maculae in the 
earlier stages on the septum and turbinals. After the second day the 
maculae disappear in the intense general redness, which may be accom- 
panied by a good deal of swelling of the turbinals and sides of the sep- 
tum. The rhinitis usually disappears with the exanthema, but in rare 
cases may lead to chronic and atrophic rhinitis. In those cases in which 



270 DISEASES OF THE NOSE AND NASOPHARYNX. 

the rhinitis is of a purulent nature on account of secondary infection it 
may provoke suppuration of the middle ear, at times of a grave charac- 
ter. Diphtheria is a rare complication. Nose-bleed of a moderate type 
occurs quite frequently, and is not serious, but in black or hemorrhagic 
measles nose-bleed is uncontrollable and a fatal complication. As the 
antrum of Highmore is developed early, it may become involved in the 
purulent forms of rhinitis in measles in children only one or two years 
old. Later in life measles may leave disease of the other accessory 
sinuses. 

Scarlatina. — In scarlatina the nose is seldom symptomatically affected, 
but when it is, the affection is apt to be of a severer grade than in mea- 
sles. The acute rhinitis of scarlatina may be a slight affection, disap- 
pearing with the exanthema. In the severer forms of scarlatina the 
phlegmonous inflammation of the pharynx may extend up into the nose, 
which is thus usually invaded through the posterior nares. In these 
intense grades of scarlatinal rhinitis the discharge is purulent and often 
offensive and bloody. If scanty, it is apt to form crusts, and the upper 
lip and borders of the nostrils become irritated, infected, and inflamed 
by the discharge, so that they appear swollen and red. On account of 
the great swelling of the nasal mucous membrane nasal respiration be- 
comes impossible. The obstruction to breathing through the nose may 
also be due to acute inflammation of Luschka's tonsil, which swells and 
fills the nasopharynx. This and the purulent rhinitis often lead to sup- 
purative otitis media, which occurs far more often than with measles, 
and is sometimes of great severity, so that the labyrinth may be destroyed 
and total and permanent deafness result in twenty-four hours. 

False membranes occasionally form on the nasal mucous surface in 
scarlatina, and though usually due to streptococcus or staphylococcus in- 
fection, they also quite often contain diphtheria bacilli of a virulent 
nature, presenting thus a mixed infection. Acute inflammation of the 
accessory sinuses may occur, and terminate in chronic empyema of one 
or more of these cavities. In the gravest forms of scarlatinal inflamma- 
tion of the nasal mucous surface portions of this may become gangrenous, 
and even caries of the bones has resulted. Chronic rhinitis, both hyper- 
tropic and atrophic, may follow scarlet fever, and many cases of ozaena 
date from an attack of it. 

Typhoid Fever. — Acute coryza is so seldom a symptom of typhoid 
fever that its presence is almost diagnostic of the absence of that dis- 
ease. The local changes in the nose that occur in typhoid fever are 
not so much catarrhal as due to the drying of the nasal secretions and 
those of the nasopharynx, a condition which is a part of the dryness 
of the integument and mucous surfaces characteristic of the disease. 
This predisposes to the adhesion of the nasal mucus to the walls of the 
nasal fossae in the form of crusts, which are especially prone to coat the 
anterior part of the septum and nasal vestibule. These scabs cause nasal 



EPISTAXIS AND NASAL AFFECTIONS IN ACUTE INFECTIOUS DISEASES. 271 

obstruction, and if removed with the finger are apt to produce nose-bleed, 
which is a prominent symptom of the first week of typhoid fever, but 
may occur at any time during its course. It almost invariably comes 
from the place mentioned in the section on epistaxis, — viz., on the an- 
terior part of the septum, — and though usually inconsiderable, has in 
some cases been severe enough to cause death from exhaustion. The 
low state of vitality of the tissues in typhoid fever and the tendency in 
the somnolency of the disease to pick at the nose may lead to abscesses, 
erosions, ulcerations, or perforations of the septum. Slight injuries may 
cause quite extensive lesions, while in health they might do no apprecia- 
ble damage. These morbid states generally run their course underneath 
crusts, and are hidden by them. 

Infiuenza. — In the acute rhinitis of influenza the bacillus of this dis- 
ease can usually be easily found by the ordinary methods. In many 
cases of influenza the nose is not involved at all. The coryza of influ- 
enza does not differ from the simple variety except in its obstinacy and 
severity. Secondary infections with streptococci or staphylococci are 
frequent, and the disease usually terminates in a long stage of mucopuru- 
lent catarrh. Epistaxis is a common accompaniment, and may be severe. 
Subjective perception of foul odors and other parosmias are frequent 
enough to be characteristic and show involvement of the olfactory mu- 
cosa. Though empyema of the accessory sinuses seldom follows influ- 
enza, this disease occurs in such wide-spread epidemics that sinus disease 
due to it is comparatively common. An eruption in the nares, with ob- 
struction of the jpassages and subsequent!}' epistaxis, is sometimes caused 
by small-pox, and cases Jire not very uncommon in which the nostrils 
have become occluded by healing of the ulcerated surfaces. 

The treatment of symi^tomatic coryza is that outlined in the descrip- 
tion of simple acute rhinitis. The swelling of the nasal mucosa and 
occlusion of the nose in mejisles may be very distressing. In older children 
a spray of cocaine, one grain to the ounce of water, may be allowed, and 
will add greatly to the patient's comfort. In younger children a soft 
brush wet witli the solution maj^ be passed into each nostril at intervals 
of an hour or two. The brush may readily be passed along the inferior 
meatus into the nasopharynx, as suggested by Catti, who em^iloys it to 
apply a 1 to 5000 solution of corrosive sublimate when the rhinitis is of 
great severity. He uses the same solution in the purulent or diphtheritic 
forms of scarlatinal coryza. A spray of adrenals will tend to keep down 
the swelling of the nasal passages. 

When typhoid patients suffer from dryness or stuffiness of the nose, 
this should always be inspected for crusts. These are to be softened with 
a spray of oleum petrolatum album, followed by a mild alkaline sjpray of 
sodium bicarbonate, a teaspoonful to a pint of water. Irrigation of the 
nose is rarely needed, as free use of the spray will keep the nares clean 
and prevent ulcerations and perforations forming under the scabs. In- 



272 DISEASES OF THE NOSE AND NASOPHARYNX. 

stead of the oily spray, vaseline fluid may be dropped into tlie nose from 
an oil- can, and will answer as well. 

In severe nose-bleed occurring in the course of symi)tomatic rhinitis 
the bleeding-point must be sought 5 it is usually on the septum at its 
anterior part. A pledget of lint packed against this may be all that is 
required to stop the epistaxis. If the bleeding come from hidden sources, 
a spray of adrenals or the application of a solution of these with a 
cotton swab to the nasal mucous surface may stop the bleeding, otherwise 
it is better to pack the nares with iodol lint rather than to subject an 
acutely inflamed nasal fossa to the irritation of astringents, which are 
inefficient and may increase the inflammation to an intense degree. 



CHAPTEE Y. 
FOREIGX BODIES IX THE XOSE. 

Foreign bodies are most often found in the noses of children, who 
place them in their own nostrils or into those of their playmates. 

In addition to the nsual way through the nostrils, foreign bodies may 
enter the nares by way of the nasopharynx and choanse. This may occur 
during the act of vomiting, or when food is violently coughed out of the 
larynx after it has accidentally lodged there. A paralyzed or defective 
soft i:)alate predisposes to this occurrence. The variety of foreign bodies 
found in the nares of children is endless. As a result of traumatism, 
bullets, pieces of knife-blades, broken lead-i)encils, etc., have entered the 
nasal cavity and lodged there. The most frequent seat of foreign bodies 
in the nose is the lower meatus ; thej' are also found in the middle mea- 
tus, or the space between the lower turbinal and septum. Cement- workers 
are liable to the formation of concretions of this material in the middle 
meatus. 

Si/mjyioyns. — Small, smooth substances of indestructible material, such 
as beads or small buttons, may remain in the nose for years, causing but 
trifling or no symptoms. As a rule, the symptoms created by the pres- 
ence of foreign bodies are marked, but often misunderstood and attributed 
to nasal catarrh. Peas, beans, and like bodies of Aegetable material 
swell and even germinate, so that the pressure their increasing size causes 
creates pain and severe irritation. Sharp-cornered substances may pro- 
duce an acute rhinitis whose cause may not be suspected. 

The nervous symptoms caused by the presence of foreign bodies may 
be severe. Intense headache and pain in the nose and cheek, often neu- 
ralgic in nature, occur. Epileptic convulsions and nasal reflex cough 
have been observed, but both conditions ceased after the offending sub- 
stance was removed. 

The most striking symptom after the offending material has lodged 
for some time is unilateral nasal obstruction with a discharge of purulent 
nature and usually offensive odor coming from one nostril only. A dis- 
charge of this kind in children up to the seventh year of age is almost 
invariably due to the presence of a foreign body in the nares, and it 
is not uncommon for parents to date back the nasal obstruction and 
unilateral discharge in a child for several years. This unilateral nasal 
suppuration embodies the danger of suppurative otitis media. The of- 
fending substance in the naris may also lead to ulceration, and even 
rarely to necrosis of the turbinated bone, on account of secondary infec- 
tion of the wound caused by its constant pressure. Polypoid outgrowths 

18 273 



274 DISEASES OF THE NOSE AND NASOPHARYNX. 

and luxuriant granulations may so bury the foreign body that it can 
with difficulty be seen, if seen at all. The smallness of their openings 
makes penetration of the accessory sinuses through their natural ori- 
fices by foreign bodies in the nose an impossibility. The antrum of 
Highmore may be the seat of foreign bodies/ and reports of these are 
not rare, but they effect their entrance through the walls of the cavity 
or i)enetrate through openings in the alveolar process. Thus bullets 
may enter the antrum, or fragments of metal, as the result of explo- 
sions. The ends of knife-blades have broken off and remained in the 
sinus maxillaris. Through the alveolar process a foreign body may 
pierce the socket of a tooth. Portions of roots of teeth may be forced 
in during extraction, or the extraction may leave an opening into the 
antrum, which may give i^assage to various substances. The antrum is 
quite tolerant of non-septic and non- irritating substances, but if sei^tic 
germs enter with the foreign body, suppuration of the sinus is to be 
expected. 

Diagnosis. — Unilateral purulent discharge in children u}) to the seventh 
year almost invariably means a foreign body in the nostril. In adults 
necrosed bone can be diagnosed hj the defects it leaves, and which are 
generally in the septum. After second dentition suppuration from the 
sinuses, especially the antrum, may have to be considered ; but though 
here there is unilateral suppuration, the probe fails to find a foreign body. 

The application of cocaine aids greatly in making the diagnosis by 
reducing the swelling and sensitiveness, so that deliberate examination 
of the foreign body becomes possible. All pus must be washed away 
before inspection of the naris is of any use. In little children it is 
usually easy to see into the nares without a nasal speculum, as their 
nostrils contain no vibrissse ; and as this instrument or any other is 
apt to cause them great terror, more can be learned without a nose- 
si^eculum than with it in their cases. In the majority of instances, 
especially recent ones, it is not hard to determine the seat of a foreign 
body in the nares; but, as an illustration of the difficulty which sometimes 
attends the diagnosis, an instance may be mentioned in which a long 
match had been inserted into the nose and been sought unsuccessfully 
by a physician. The mucous membrane was so swollen and the naris so 
filled with secretion that the object was found only after carefully wiping 
this away and feeling backward with the probe along the floor of the 
nasal fossa. 

Foreign bodies in the accessory sinuses can be diagnosed by means of 
the Eontgen rays, and those lying in the nasal fossse can also be photo- 
graphed in this manner, as has been proved by Scheier. 

Prognosis. — Small bodies, by the accretion of chalky deposits, may 
become the nuclei of rhinoliths. They are, as a rule, not dangerous, 
but in most instances, sooner or later, they provoke an extremely offensive 
discharge. 



FORETGX BODIES IN THE NOSE. 275 

Treatment. — Foreign bodies which have recently lodged, and are of 
the prox)er shaj)e, can often be expelled by blowing air into the unob- 
structed nostril hj Politzer's method. The attempt to accomplish the 
purpose in like manner with water is inadmissible, as this would be very 
apt to enter the middle ear and cause otitis media. Before attempting 
instrumental removal the nasal fossa should be anaesthetized with cocaine. 
The best of these for the removal of foreign substances is the steel- wire 
snare. In one instance a wild tooth was extracted from the floor of the 
naris in this way. It had caused a catarrhal discharge for several years. 

Foreign bodies near the front of the nostril can often easily be re- 
moved by passing a bent probe behind them and raking them forward. 
A small spoon on a flexible shank, like an ear-spoon, can also be used. 
It may be necessary to employ nasal forceps when large foreign bodies are 
so wedged that neither wire snare nor instrument can pass behind them. 
If hard and smooth, the offending material is liable to be pushed back 
and out of the choanse into the nasopharynx, whence it may drop into 
the larjmx and cause suffocation. AVhen there is danger of a strange 
substance following this course it is well to have the index-finger in the 
postnasal space to control its movements, as advised by Moritz Schmidt. 
It may be necessary to anaesthetize very unruly children. Foreign bodies 
which have swollen until tightly held, or have so wedged themselves 
across the naris that they cannot be extracted without violence, may need 
reduction in size before removal. This can be accomplished by nasal 
cutting forceps or by the trephine. As soon as the offending substance 
is removed the pathological changes it has excited speedily subside in 
almost all cases. This is true even of those neglected cases in which the 
foreign body has been lodged in the nose for years. 

Bhinol'dhs. — Ehinoliths are cretaceous masses of comparatively rare oc- 
currence, which usually owe their origin to the lodgement in the naris of 
some foreign substance u^Don which calcium phosi^hate, calcium carbonate, 
and other mineral substances are gradually deposited from the secretions. 

It is suj)posed that blood- clots may at times give rise to rhiiioliths. 
It is very improbable that they are ever of spontaneous formation. 
Ehinoliths are apt to be much more formidable as regards symptoms 
and difficulty of removal than simple foreign bodies. This is due to their 
tendency to grow to a large size and to their frequently rough surface. 
They may occupy both lower and middle meatus or perforate the sep- 
tum narium. Their shape is usually irregularly ovoid, but some have 
sharp corners, others merely a rough surface, while some are smooth, 
and many adapt themselves to the shape of the turbinals, of which they 
form, in a measure, casts. Their color is generally grayish brown or 
yellowish, greenish, grayish white, dark brown, or dark green, and they 
are often brittle and friable. They may reach a comparatively large 
size, weighing from one-quarter to one-half ounce, and may exist in the 
nose for a long time before removal. 



276 DISEASES OF THE NOSE AND NASOPHARYNX. 

The symj)toms are the same as those caused by foreign bodies of 
simple nature, only generally intensified. Thus, epistaxis is apt to 
accompany the foul discharge occasioned, and headache and neuralgic 
pains in the cheek, extending to the eye and forehead, are common. 
Swelling of the nose, inner part of the eyelid, and cheek on the same side 
as the foreign body has been described in a number of cases. Two cases 
of meningitis are reported, in one of which a splinter of wood had pene- 
trated the ethmoid bone and caused a rhinolith and suppuration. 

Examination of the nose shows it to be filled with purulent secretion 
and crusts. When these are removed the rhinolith is discovered, usually 
bedded in granulations or hidden by polypi. As complications, per- 
foration of the septum, ulcerations leading to necrosis of the turbinated 
bones or nasal floor, abscess of the septum, and empyema of the antrum 
have been found. 

The diagnosis is less easy than it is in the case of simple foreign 
bodies, for the secondary changes are greater, the granulations and poly- 
poid growths hide the concretion, and it is hard to tell it from osteoma 
or portions of necrosed bone in syphilis. The disease has also been mis- 
taken for carcinoma. An examination with the probe is the surest means 
to avoid error. Ehinoliths are to be distinguished from malignant disease 
by their slow growth and the less degree of pain that accompanies them 
on inspection and palpation with the probe. Ehinoliths are movable in 
the nasal fossa, while osteomata are fixed and cannot be penetrated by a 
sharp needle as can a rhinolith. 

Treatment. — The methods of removal of rhinoliths are essentially 
the same as those employed to extract simple foreign bodies. As they 
are generally of larger size and rougher material than these substances, 
they offer more resistance to efforts to withdraw them. It is therefore 
more often necessary to break them down before removal, and the 
methods described with foreign bodies will usually suffice for this purpose. 
In addition to these, lithotrites have often been emi)loyed with success, 
and the rhinolith may be reduced in size by the repeated application of 
minute portions of mineral acids with a roughened probe, as suggested 
by Bergeat. In some cases it is better not to attempt to extract the 
concretion from in front, but to push it into the nasopharynx, while the 
finger is introduced behind the velum as a guide to keep the rhinolith 
from getting into the larynx. It can also be seized from the nasophar- 
ynx by means of a small-bladed pair of Lowenberg's forceps, after it has 
been pushed back through the choana. The finger is also to be used here 
as a guide. 

Maggots in the Nose. — Nasal disease due to invasion of the nasal cav- 
ity by the larvae of certain species of flies, though common in tropical 
countries, is quite rare in temperate latitudes ; not so rare, however, 
as to prevent an extensive literature on the subject. The flies liable 
to deposit eggs in the human nares belong to the genus oestrus, or gadfly 



FOREIGN BODIES IN THE NOSE. 277 

(not the horse-fly), and the muscid£e, or that family of flies to which the 
common house-fly belongs. Though the larvse of the genus oestrus have 
been found in the human nose, this is a very rare occurrence as compared 
with the frequency of those of the genus muscidae in the same location. 
Where oestrus larvse live in the human nasal passages they do not cause 
destruction of tissue, but simply irritate the surface of the mucosa. In 
this they differ from those of the muscidae, which may cause the most 
frightful destruction of the nasal interior. The common house-fly is 
innocent of causing nasal disease, but some of its near relatives of the 
genus muscidae belonging to the order of sarcophagi are dangerous. One 
variety of these is the sarcoi:)hagus Wohlfahrtii, a fly resembling the 
large gray flies seen on carrion. The sarcophagus Wohlfahrtii is shy 
and is found only in the open country. It lays its eggs in the noses 
of sleepers in the open air in daytime, and is especially apt to do so in 
the nasal cavities of people with offensive discharges. Another variety 
of muscidce is far more dangerous, as it is found in all latitudes from 
Canada to Central America, is not at all shy, and enters houses, acting 
as imi)udently as does the common house-fly or the bluebottle-fly. It 
will lay its eggs in the nostrils of people who are not asleep, and though 
it shows a preference for diseased nasal cavities, it does not spare healthy 
ones. This fly is responsible for most of the cases of maggots or ' ' screw- 
worms" reported. It causes the disease called Peenash in India, where 
maggots often cause great destruction of the structures of the nose. 
This fly is called the Compsomyia macellaria, CalUphora antrojyhaga, or 
Lucilia macellaria. 

SupiDuration ensues, with periostitis, perichondritis, and necrosis of 
bone and cartilage. All of the soft parts of the nasal interior may be 
destroyed, the necrotic bones are cast off, and the external nose may be 
merely represented by its integument. The turbinated bones, the sep- 
tum, the ethmoid, the sphenoid, the i^alate, and even the superior maxil- 
lary bones may be totally destroyed, and inflammation of the meninges is 
likely to follow. The soft palate is also in some cases eaten away in the 
course of time, so that the maggots enter the oral cavity. In one case 
the hyoid bone was necrosed. The maggots may also work their way 
through the integument of the external nose. Swellings resembling 
abscesses form, which burst and discharge the larvse. In others the 
destruction is more limited, and produces merely ulceration or necrosis 
of the cartilaginous septum or perforation of the soft palate. 

Symptoms. — The symptoms rapidly follow the deposit of eggs by the 
female fly, as the eggs hatch in twenty-four hours and the larvse grow 
speedily to their full size. At first there are merely irritation and tick- 
ling in the nose, with slight discharge ; but the tickling rapidly increases 
to unendurable formication, with violent sneezing. As the larvse begin 
their destructive burrowing, pain makes its appearance. Persistent 
headache, rapidly increasing to agonizing intensity, with exacerbations 



278 DISEASES OF THE NOSE AND NASOPHARYNX. 

that are nearly unendurable, is a most prominent symptom, as is also 
aching in the region of the cheek or forehead on one or both sides. All 
the branches of the trigeminus, even the inferior dental nerves, may be 
involved in the irradiating pain. This is probably the result of extension 
of the inflammation to the frontal and other sinuses, or to the actual 
entrance of these cavities by the maggots. The face swells, presenting 
the appearance of erysipelas on one or both sides, while abscesses appear, 
burst, and discharge j^us and larvae. The destruction of the nasal interior 
may result in great disfigurement, as the nose refracts and sinks in. The 
discharge consists of foul-smelling serum of bloody character, or of serum 
with mucus that trickles from both nostrils. Severe and repeated epi- 
staxis marks the course of the disease and helps to exhaust the patient, 
the -psdn being so great as to end in delirium or attempts at suicide. 
Meningitis seems to be a rather frequent termination, with convulsions 
and coma. Sepsis and pyaemia may add their symptoms to the severity 
of the disease in its later stages. 

Diagnosis. — The great rarity of the affection will lead the observer to 
think of every disease but maggots in the nose until inspection brings 
the worms to view or some of them are seen in the discharge. The 
larvae are apt to group themselves in the back part of the nasal fossae, 
where they hang in clusters about the choanae. 

Prognosis. — Early recognition is of the utmost importance. When 
there is great destruction of the nasal structures, when the sinuses have 
become filled with larvae, which have thus become i^ractically inacces- 
sible, or when there is meningitis or sepsis, the outlook is usually posi- 
tively bad. Cases recognized early may escape with but little damage. 
Much depends on the variety of larvae, as those of the gadfly do no 
damage to the tissues, while those of the muscidae are terribly destruc- 
tive. 

Treatment. — Sleeping in the open air in the daytime is a dangerous 
practice for those affected with nasal catarrh. The destruction of the 
maggots is best accomx^lished by chloroform, which seems preferable to 
all other agents. In some instances inhalation of chloroform only is suf- 
ficient to effect a cure. When this does not succeed, the patient should 
be fully anaesthetized and the nasal cavities thoroughly syringed with 
pure chloroform. This does not seem to affect the mucous membrane 
deleteriously, but it would cause extreme pain if the patient were con- 
scious. Some have been successful in relieving the disease by carefully 
picking the maggots out one by one with the nasal forceps, and this may 
be tried in the less severe cases before resorting to chloroform. 

Other Animal Parasites in the Nose. — Insects of the order of myriapods, 
to which the centipedes belong, have in very rare instances crawled into 
the nares of sleeping individuals. They are apt to seek a home in the 
accessory sinuses, especially the frontal, and have been known to re- 
main in the nose or accessory cavities for a long period, even as long as 



FOREIGN BODIES IX THE NOSE. 279 

four years. They may leave the nose of their own accord, or be sneezed 
out. Their presence causes severe nervous symptoms and intense local 
pain, especially great if the insect is in the frontal sinus. Other living 
creatures that have infested the nose with similar symptoms are the ear- 
wig (ForficuJa auricularia), caterpillars, scorx^ions, and termites. Leeches 
have been carelessh" allowed to crawl into the nose, with such serious 
consequences in one case that death resulted from prolonged nose-bleed. 
There are manj^ reports of the appearance of ascaris lumbricoides in 
the nasal cavity and the accessory sinuses, the frontal sinus especially. 
The nervous symptoms caused by its i)resence may be severe headache, 
syncope, and vomiting. The treatment of animals in the nose is essen- 
tially that of maggots in the nose. AVhen visible, the intruders can be 
extracted with forceps. 



CHAPTEE VI. 

CUTANEOUS DISEASES, DEFORMITIES, AND INJURIES OF THE NOSE. 
FUEUNCULOSIS OF THE NOSE. 

This affection, though a minor one, is important because of its fre- 
quency and the pain and temporary disfigurement it causes. The infection 
is due to the entrance of staphylococci into the follicles of the vibrissse 
within the nostrils. In this situation the furuncles are very hard to see 
until ready to discharge, as the dense nature of the tissues of the alse 
nasi keeps them from rising above the surface as does the ordinary boil. 
Furuncles also occur on the outer aspect of the nose. Eczema and the 
irritation of the cutaneous surface within the nostrils due to nasal dis- 
charges predispose to the formation of boils. As elsewhere, one furuncle 
is liable to be followed by another or several in succession, the redness 
and swelling of the external nose being often very disfiguring. As soon 
as the slough and pus are discharged recovery is rapid. Occasionally 
furuncles in the nasal vestibule lead to abscess formation of considerable 
extent, with fever and great pain. 

Treatment. — If an abscess form, it should be opened as soon as the pus 
has collected. When the slough is ready to separate a small incision will 
usually suffice to free it. Until the time has come for incision, cotton 
moistened with a saturated solution of boric acid should be kept within 
the nostril to soften the epidermis and permit the boil to open spontane- 
ously. Prevention of recurrence is sometimes accomplished by painting 
the cutaneous region within the nostrils with a one-half per cent, solution 
of corrosive sublimate in alcohol, three times daily, or the application, 
twice daily, of an ointment of corrosive sublimate three-fifths of a grain, 
distilled water forty-five minims, and enough lanolin to make two and 
one-half drachms ; but in obstinate cases furuncles will recur in spite of 
all measures. In such instances the urine is to be examined for sugar, 
as diabetes may exist as a predisposing cause. Of internal remedies 
potassium chlorate has seemed the most serviceable for the prevention 
of furunculosis. 

LUPUS OF THE NARES. 

Lupus is a process much like the slower and less malignant types of 
tuberculosis, which are accompanied by cicatricial tendencies, and may 
perhaps present a form of tubercular disease in which the body cells 
offer unusual resistance to the evil influence of the tubercle bacilli. The 
opinion of to-day is that tuberculosis and lupus are due to the same cause, 
— viz. , the tubercle bacillus. The disease in the nose is very chronic and 
280 



CUTANEOUS DISEASES, DEFORMITIES, AND INJURIES OF THE NOSE. 281 

is usually secondary to lupus of the external nose. It generally occurs 
in young persons of strumous habit and is most liable to affect young girls. 

Etiology. — The disease is sux:>posed by the majority' to be a form of 
tuberculosis, but there are good observers who dissent from this view, 
holding that too much importance is attributed to the scant presence of 
tubercle bacilli as an etiological factor, and that the disease is essentially 
different from tuberculosis. It is certain, whatever the relationship be- 
tween the two diseases, that lupus is often followed by the appearance of 
tuberculosis elsewhere in the body. Lupus of the nares usually follows 
facial lupus, but may precede it. Abrasions at the nasal entrance and 
chronic coryza with eczema narium are conditions greatly favoring 
infection with the tubercle bacillus. 

PathoJogy. — Lupus of the nares is usually seen in the form of hqms 
exedens, or the ulcerating form. The seat of the disease is almost invari- 
ably the cartilaginous septum. From here it spreads to the nasal floor 
and turbinals. It generally spares the bony structures of the nose, differ- 
ing in this from syphilis. The characteristic product of lupus (the nodule) 
appears here as it does on the skin, but differs in its deeper red color and 
slight elevation above the surface. The size of the sei^arate nodules is 
that of a millet-seed, and so closely are they usually crowded together 
that they form an irregular red surface that is firm and infiltrated, resem- 
bling somewhat an area covered with red granulations, but much firmer 
to the touch. The patch of lupus is usually covered by scabs, which 
need removal before it can be inspected. Ulceration is slow, and shows 
no great inclination to become deep rapidly, spreading rather on the 
surface by the formation of fresh nodules while at some other portion 
of the lesion cicatrization may be in progress, the ulcer thus acquiring 
a serpiginous character. The margins of the ulceration are generally 
indurated and slightly elevated, while the ulcer itself is of a shallow, 
ragged character, until in the course of time it gradually deepens and 
perforates the sei)tum in its cartilaginous portion. The microscopic 
anatomy is the well-known one of the miliary tubercle, and tubercle 
bacilli are usually sparsely present. 

In Jiqnis non-exedens the new-formed lupous tissue does not ulcerate, 
but is absorbed and organized into cicatricial tissue, causing retracting 
scars and atrophy of i^ie structures involved. 

Symptoms. — The beginning of lupus is slow and insidious, the first 
symptoms being those of a chronic rhinitis with watery discharge, that 
later becomes thicker and shows a tendency to dry in the form of scabs. 
At the same time the nasal vestibule becomes the seat of an eczematous 
condition causing fissures and crusts to form on the rim of the nostrils, 
and the external nose and upper lip are apt to swell at the same time. 
The patient thinks that he has merely an obstinate cold in the head, and 
generally puts off going to a physician until the disease has made such 
progress that its eradication has become difficult or imj)ossible and the 



282 DISEASES OF THE NOSE AND NASOPHARYNX. 

prospect of deforming cicatrices great. Pain iu nasal lupus is slight or 
absent, another reason for the patient's paying little attention to his 
symptoms. 

Inspection early in the disease may present more the appearances of 
chronic rhinitis, with crusting and scabbing of secretions and accompany- 
ing eczema, than of so serious a disease as lui^us, and close attention may 
be needed to discover the characteristic lupous granulations. However, a 
rhinitis of this character occurring in a young woman, together with 
swelling and redness of the tip of the nose and of the upper lip, is 
suggestive of lupus. 

Later in the disease the turbinals may be the seat of true lupous tissue, 
and the inspection of the deeper parts of the nares be prevented by the 
masses of granulations. Some of the lupous nodules feel resistant and firm 
to the touch of the probe, while others which have softened may readily be 
punctured by it, as may also the eroded cartilage in i)laces. Cicatrization 
may be seen in parts, while in other regions fresh infiltration is in progress. 
Cicatrization results in shrinking of the sei:>tum, retraction and deformity 
of the external nose, and in some cases narrowing of the lumen of the nares. 

Diagnosis. — When lupus of the nares is preceded by that of the ex- 
ternal nose the diagnosis presents but little difficulty, except in those rare 
cases in which tuberculosis and lu]3us are associated ; but when the ail- 
ment begins in the form of a chronic rhinitis with eczema, only painstaking 
examination will enable one to arrive at a conclusion. 

It may be impossible to distinguish lupus in the nares from the in- 
filtrative form of tuberculosis until the more ra^^id progress of the latter 
and the signs of tuberculosis elsewhere clear up the matter. The diagnosis 
has, however, a scientific rather than a practical value, as the treatoient of 
the two conditions is essentially the same. The diagnosis from syphilitic 
ulcer and infiltration, especially when the ulcers are superficial and 
serpiginous, may be by no means easy, and a course of potassium iodide 
may be needed to remove one's doubts. The distinguishing points in 
ordinary syphilitic ulceration are the sharp clean-cut border and great 
depth of most syphilitic ulcers, their rapid progress^ and the deep red of 
the indurated tissues about them. Lupus almost never attacks the bones 
of the nose, syphilis frequently does so. Sarcoma is not so rare on the 
septum that it may not have to be considered, but its rapid growth, with 
the creation of a tumor, and the absence of ulceration distinguish it. 
Epithelioma may present difficulties in the beginning, but the excision of 
a piece for microscopic diagnosis should make the matter clear. 

Frognosis. — The slow advance of the disease is a favorable element in 
its prognosis, but its tendency to spread by infiltration of the tissues by 
means of scattered minute nodules which may invade the structures at 
some distance from the original site makes it hard to eradicate. It also 
has a strong tendency to recur in the scars left after operation, possibly 
on account of infection of the wound at the time. If seen in the early 



CUTANEOUS DISEASES, DEFORMUriES, AND INJURIES OF THE NOSE. 283 

stage, when the disease is circumscribed, it may be eradicated ; but if it 
lias made much advance this becomes impossible. The disease shows 
little tendency to involve the lymphatics or lymph-giands, but may lead 
to the development of lupus of the pharynx or larynx, or later to the 
appearance of pulmonary tuberculosis. It is also liable to spread from 
the interior of the nares to the face. 

Treatment. — The destruction of the lui:)ous tissue by curettement and 
lactic acid has attained the first i^lace among therai^eutic methods. All 
diseased tissue is to be energetically scraped away with the sharp spoon, 
the instrument penetrating a little into the healthy structures. The fria- 
bility of the diseased tissues makes them more easj" of removal than the 
healthy ones, so that the resistance ofi'ered by these to the instrument 
indicates how far one must go with the curette. If the disease extend 
through the sei:)tum there must be no hesitation in perforating it. The 
raw surface left by the curette is to be vigorously rubbed with pure 
lactic acid. The site of the disease should be closely watched, and all 
suspicious x>laces scraped away at intervals of from three to six weeks. 
Among other methods of treatment, cauterization with the gal van o-cautery 
is iirobably the best and affords very satisfactory results. Complete re- 
moval by the knife is sometimes i^ractised. 



KHINOSCLEROMA. 

Like many other rare affections, this disease is doubtless often unrec- 
ognized. Its chief characteristic is the i^roduction of a i)eculiar connec- 
tive-tissue growth in the mucous and submucous tissues of the respiratory 
tract. This new-formed connective tissue undergoes hyaline degenera- 
tion to a large degree, so that in consequence it forms nodes, tuberosi- 
ties, and infiltrations almost cartilaginous in hardness. Later the new 
tissue atrophies and organizes into dense cicatrices. As the disease may 
invade any portion of the respiratory tract, from the bronchi outward to 
the external nose, it has been suggested to substitute for the name rhino- 
scleroma that of scleroma. 

Etiology. — The transmission of rhinoscleroma from one individual to 
another has not been observed, so that there is no i^roof of its possessing 
contagious proj)erties. 

Pathology. — Ehinoscleroma may be located in the nares, pharjmx, 
larynx, trachea, or bronchi, or may involve several or all of these parts 
together, and may also attack the integument of the external nose and 
upper lip. Its characteristic lesions in the nose are protuberances and 
nodes that rise from the surface of the mucous membrane and diffuse 
infiltrations of the submucous tissues. The prominences vary from the 
size of a millet-seed to that of a pea. The diffuse infiltration of the 
submucous tissue is of a rigid, firm consistency, and greatly obstructs 
the lumen of the nasal fossa or entirely closes it. 



284 DISEASES OF THE NOSE AND NASOPHARYNX. 

The disease generally originates in tlie nasopharynx in the salpingo- 
palatal fold, and advances through the nasal cavity nntil it reaches the 
vestibule of the nose. Here it usually halts^ but often it also invades the 
external nose, upper lip, and gums. In many cases it is primary in the 
larynx or trachea, and may cause fatal stenosis of these and the bronchi 
as it descends. 

In the nasal vestibule the disease appears in the form of diffuse infil- 
tration, which may form voluminous folds which protrude from the nos- 
tril as bluish-red tumors of the size of a cherry. 

It is not usual for the infiltration to go farther than the rim of the 
nostril ; when it does so it may enlarge and deform the nose greatly, so 
that the latter may even attain the size of a fist. When the upper lip is 
invaded it assumes the shape of a protruding snout, while the swelling 
may obliterate the space between the lip and gums. The infiltrated 
portions of the skin have a cartilaginous hardness, while the cutaneous 

surface presents a glazed appearance, as 
^^'^- 1^^- if tightly stretched over the infiltrations. 

The color of the skin may be white or 

,\ 

/ / I B^^ ^.^ Though ulceration of the scleroma- 

■^ • s -^ ^ |-Q^g tissue is never great, fissures are 

V -, apt to occur which may become deep 

( 1 .;/ \ '-/ \| ^ enough at the junction of the ala of the 

^^^^'" ''^^^^ 3 nose to the face to sever the ala from 



/^ , \ bluish brown. Modules of pea size may 

./^ y2% itf^ ^- ^^^^ ^^ ^^^^^ upon it. 



\. ;,# its base. 



The scleromatous infiltration of the 
Rhinoscopic image in rhinoscieroma. nodules, wherevcr found, results finally 

Both lower turbinals are much infiltrated, .,, i ,. j> - / • - t j_- 

causing tumor-like prominences, (stoerk.) m the formation of Cicatricial tissue as 

the nodules shrink. In this manner the 
soft palate becomes drawn towards the roof of the pharynx, making 
posterior rhinoscopy imperfect or impossible. Eetraction and disap- 
pearance of the uvula are very characteristic features of the disease, and 
cicatricial distortion of the Eustachian orifice may result in deafness. 

Histologically, the first change is invasion of the tissue by round 
cells, which later become spindle cells and organize into new connective 
tissue. Kot peculiar to the microscopic appearance of rhinoscieroma, 
but still very characteristic of it, are the so-called Mikulicz cells. These 
are large, pale cells which have undergone hyaline degeneration. Hya- 
line material is also found in the shape of larger spheres or agglomera- 
tions of these into masses, or in the form of granules, and the hyaline 
degeneration may invade the connective-tissue fibres. The hyaline ma- 
terial gives to the scleromatous infiltration its firmness, and is the chief 
histological characteristic of the disease. A micro-organism, the bac- 
terium of Frisch, exists in large numbers in the Mikulicz cells, and may 



CUTANEOUS DISEASES, DEFORMITIES, A^'D INJURIES OF THE NOSE. 285 

also be found in the round cells, in the interstices of the connective 
tissue, and in the epithelial cells. It is surrounded by a gelatinous, 
brightly refracting capsule, inside of Tvhich its body appears as a little 
dark rod, looking much like a diplococcus in lively motion. These bac- 
teria can easily be cultivated, and resemble the pneumococcus and oz?ena 
bacillus in appearance, but differ from these by their slight virulence 
and the fact that they do not curdle milk. The bacteria accumulate in 
collections which are hard to distinguish from the hyaline masses, theii' 
translucent capsules causing this appearance. The bacterium of Frisch is 
considered by most of those who have studied the disease to be its cause. 
Symptoms. — At first the patient is troubled with what seems to be a 
chronic nasal catarrh that extends gradually from the nose to the pharynx 
and larynx. This lasts, as a rule, for several years, the secretion becoming 

Fig. 104. 





Both choause are narrowed by semicircular folds and membranes. The tubal openings have 
disappeared as the result of rhinoscleroma. (Stoerk.) 

gradually purulent, and finally drying into scabs and crusts within the 
nares and pharynx. The crusts emit a foul odor that is different fi^om 
that of ordinary ozsena, and seems to be peculiar to the disease. In 
this stage the scleromatous tissue begins to make its appearance, 
oftenest first on the salpiugopalatal fold. Xext in frequency it makes 
its first invasion in the choanse, less often in the larynx, stiU less often in 
the pharynx, and with least frequency in the trachea. From these first 
sites the scleromatous tissue spreads, and finally invades large x)arts of 
the respiratory tract, even narrowing the bronchi. Usually not until 
the disease causes marked obstruction to breathing does the patient, who 
is generally of low intelligence, seek relief. Another reason for the 
patience with which the affection is endured is its painlessness and 
extreme chronicity, decades passing before there is any appreciable 
advance. 



286 



DISEASES OF THE NOSE AND NASOPHARYNX. 



Fig. 105. 



Diagnosis. — The symptoms most noticeable in rhinoscleroma are its 
very chronic course, its invasion of the larynx, trachea, or pharynx in 
addition to its appearance in the nose, the cartilaginous hardness of the 
infiltrations, and the fact that the cicatrices resulting from them are not 
preceded by ulceration. Xotable points also are the broadening of the 
external nose and its deformity by nodes and tumor-like masses, some of 
which may be seen protruding from the nostrils as bluish-red lumps. 

Syphilis in its tertiary form also leads to cicatrices, but these are pre- 
ceded by ulceration, and the course of the disease is usually rapid. 
Ehinoscleroma ordinarily attacks both nostrils symmetrically, while 
syphilis is of irregular location, but generally attacks the septum. The 
more obscure infiltrative forms of tertiary syphilis can be diagnosed by the 
effect of potassium iodide. 

Microscopic examination of the tissues and the detection of the charac- 
teristic micro-organisms in the cells 
of Mikulicz, or their cultivation, are 
needful to establish a positive diag- 
nosis of rhinoscleroma. In old infil- 
trations which have partly cicatrized 
the detection of the bacterium of 
Frisch may be difficult. 

Frognosis. — Rhinoscleroma en- 
dangers life only when it involves 
the larynx or air-passages below it, 
as here it may cause fatal stenosis. 
The disease is incurable, but opera- 
tive interference may give the pa- 
tient some relief for long periods of 
time, as the advance of the affection 
is exceedingly slow and recurrences 
a long time in appearing. 
Treatment— The treatment of rhinoscleroma is entirely operative. 
Even radical removal of the tissue early in the disease will not prevent 
its local recurrence or gradual invasion of other parts, so that sooner or 
later it will involve the larynx, trachea, pharynx, or face, when the 
primary location is in the nose. For this reason operative measures 
should be merely palliative in character and designed to relieve the 
stenosis. 

The wounds left after extirpation of the tissue heal readily. The 
tuberous growths in the nasal vestibule and diffuse infiltrations elsewhere 
are best removed with a sharp bistoury. Outgrowths within the nose, if 
soft, can be taken away with the snare, while harder masses of sclero- 
matous tissue are to be first scraped away as much as possible with the 
sharp spoon, and the operation finished with the gal vano- cautery or 
forceps with cutting beak. 




Bacillus of rhinoscleroma. (Moritz Schmidt 



CUTANEOUS DISEASES, DEFORMITIES, AXD INJURIES OF THE NOSE. 287 

The nasal skeleton slionld be left intact, and resections of portions of 
it are inadvisable. Partial removal of the scleromatous masses, when 
their radical extirpation is impossible, will give relief to the nasal 
stenosis for a long time, and the effect may be j)rolonged by the nse of 
hard-rnbber or metal tubes. The operations can be performed with the 
aid of the nasal speculum, and if narcosis be employed, the position of the 
hanging head — that is, the head hanging backward over the edge of a 
table — is a good one to observe in order to keep blood out of the larynx. 
It is best to leave the facial deformities untouched, as their return is inev- 
itable, and frequent plastic operations would be needed to cover the 
defects left by their removal. 

DISORDERS OF THE SENSE OF SMELL. 

Anosmia. — Hyposmia is diminution, anosmia, absence of the sense of 
smell. 

Anosmia and hyposmia are subdivided into respiratory, essential, and 
central, according to the seat of the lesion. In respimtonj anosmia the 
olfixctory region is intact, but shut off from the air-current by obstacles, 
so that odors cannot reach it, or the nasal fossoe may be much enlarged, 
as in atrophic rhinitis, or the air-current may be deflected, as in cleft 
palate, so that the stream of air may foil to enter the olfactory region and 
anosmia result. The prognosis of respiratory anosmia is better than 
that of the other varieties, as the obstruction to the entrance of air into 
the olfactory region can generally be removed. The treatment is entirely 
according to the cause. It may be possible, by removal of a polj^Doid 
enlargement of the middle turbinal, to restore the sense of smell at once 
after it has been absent for many years. The long disuse of the olfactory 
nerves in respiratory anosmia is thought by some to result in their 
atroph5\ Certainly in some cases the sense of smell is slow in return- 
ing after the obstruction has been removed. 

JEssentiaJ anosmia is due to inhibition of function, destruction, or atro- 
phy of the nerve-branches of the olfactory nerves or the olfactory cells 
and their epithelial sui^porting cells on the surface of the mucosa of the 
olfactory region. Acute catarrhal inflammations may injure the ciliated 
ends of the olfactory nerve- cells enough to cause temporary anosmia. 
These and the olfactory cells may have their functions temporarily sus- 
pended by poison applied to their surfaces. The most striking effect is 
obtained by cocaine, but morphine and atropine will cause the same 
result. Astringents or antiseptics, if api^lied in too concentrated a form 
to the olfactory region, will create anosmia, so that repeated and strong 
applications of this character are to be avoided, and, as a rule, normal 
salt solution is to be preferred for nasal irrigations. Excessive irritation 
of the olfactory nerves by strong odors may cause total anosmia. Pus or 
crusts in the olfactory region will inhibit the sense of smell. In atrophic 
rhinitis anosmia usually appears in the later stages, and atrophy of the 



288 DISEASES OF THE NOSE AND NASOPHARYNX. 

olfactory nerve-cells, epithelial metaplasia, and enlargement of the nasal 
passages are the probable causes of this form of anosmia. Keiiritis 
following diphtlieria or influenza may lead to loss of the sense of smell 
if the olfactory nerves be involved. Dryness of the mucosa of the 
olfactory fissure may cause hyposmia or anosmia. The removal of the 
Gasserian ganglion in human beings results in a marked diminution of 
the acuteness of the sense of smell, the reason of which is not under- 
stood. 

Ce7itral anosmia may be caused by atrophy of the olfactory bulbs or 
by their injury in fractures, such as those of the cribriform plate. In- 
tracranial diseases may be the origin of this form of anosmia by pressure 
on the olfactory bulbs, and tumors, especially those of syphilitic origin, 
meningitic exudates, extravasations of blood, or subdural abscesses in 
the anterior fossa of the skull may produce this. Gunshot injuries of the 
olfactory bulb have caused anosmia. Although the cerebral centre of the 
sense of smell is unknown, it has been observed that dropsy of the ven- 
tricles, embolic, hemorrhagic, and sclerotic changes in the cerebral sub- 
stance, and brain -abscess may result in anosmia. It is also one of the 
rarer manifestations of hysteria. 

The prognosis of essential anosmia is according to its cause. When 
this is central the outlook is usually bad, except in those cases due to the 
presence of syphilitic gummata. Diphtheritic and influenza anosmias 
generally recover. The treatment must be guided by the etiology. In 
neuritic cases the local application of strychnine solutions has proved 
of benefit. Syphilitic cases are to be treated by large doses of potassium 
iodide. 

Hyperosynia. — There are considerable variations in different individu- 
als in the acuteness of the sense of smell, so that its pathological inten- 
sification can be predicated only when it becomes an annoyance to its 
possessor. The condition may also be one of increased irritability of 
the individual rather than of extraordinary acuteness of smell; so that 
odors which do not disturb or may even please others are disagreeable 
to him. This explains the fact that hyperosmia has so frequently neu- 
rasthenia, hysteria, angemia, or pregnancy as a basis, and, in short, 
generally occurs in people either temporarily or chronically nervous. 
Such people may find minute amounts of tobacco-smoke and the odors 
of certain flowers or drugs intolerable, and may even be subject to 
reflex disorders in consequence, such as headache, vomiting, palpitation, 
faintness, and asthma. Hyperosmia of this type occurring in nervous, 
hysterical, or ansemic individuals is doubtless central in origin, and 
has its seat in the cerebral hemispheres. Eespiratory hyperosmia may 
exist when the air-current is for some reason unduly deflected into the 
olfactory fissure. Toxic hyperosmia may result from the local appli- 
cation of strychnine to the olfactory mucosa, and may also follow its 
general use. 



CUTANEOUS DISEASES, DEFORMITIES, AND INJURIES OF THE NOSE. 289 

Treatment. — Toxic liyperosmia and that due to pregnancy depart with 
their causes. The form accompanying neurasthenia or hysteria may 
be improved or relieved by those remedies which make the body more 
robust and the nervous system more resistant to impressions. In addition 
to this the local application and general use of potassium bromide have 
proved of service. The disease may be extremely obstinate and intrac- 
table, and in many cases incurable. Potassium bromide is to be used in 
the form of a spray in a one or two i^er cent, solution. Weak solutions 
of astringents may also be tried, but are not well borne in the upper 
part of the nose. 

Farosmia. — In parosmia there is perversion of the sense of smell', 
odors are not i^erceived correctly, or else the individual is conscious 
of odors which do not exist, but are subjective, a condition analogous 
to tinnitus aurium. Those odors which are due to putrid intranasal 
or pharyngeal conditions, and are noticed only by the individual, — so- 
called kakosmia subjectiva, — are commonly considered with true ner- 
vous parosmia. 

Parosmias of nervous origin occur in neurasthenic, In'sterical, or 
pregnant persons, and often in those mentally diseased. The subjective 
odors perceived are usually disgusting or disagreeable. Parosmia may 
follow influenza, and here it is probably due to direct irritation of the 
olfactory mucosa. It may precede epileptic attacks as an aura. When 
this occurs it is always well to examine the nose for diseased conditions, 
especially empyema of the sinuses, as some cases of epilepsy have been 
relieved by treatment of such states. Parosmia may be due to disease of 
the olfactory bulb or tract, the gyrus occipitotemporalis, the gyrus hip- 
pocami:>i, and the pes hip]30cami)i major. 

Diagnosis. — The diagnosis of j)urely nervous parosmia is to be accepted 
with extreme caution, as subjective perception of foul odors is often due 
to some local diseased state. The cases of parosmia due to central causes 
are usually not capable of improvement. Those caused by influenza re- 
cover. Local causes for subjective bad odors are to be carefuU}^ searched 
for. Those cases dependent ui^on neurasthenia and other general ner- 
vous states should receive the same treatment as for hypei'osmia. 



CONGENITAL DEFORMITY OF THE NOSE. 

The nasal passages may be congenitally occluded in their anterior 
portion by a cutaneous diaphragm, while the choanae, when closed, are 
occluded by bone, a i)late of this being derived from the vertical portion 
of the palate bone. Membranous closure in this region is not congenital, 
but always the result of syphilis, diphtheria, or other disease process. 
The bony plate is covered on both sides with mucous membrane, is very 
thin, and is placed not exactly transversely and vertically, but, as a rule, 
somewhat obliquely. In these cases anosmia exists until the obstruction 

19 



290 DISEASES OF THE NOSE AND NASOPHARYNX. 

is removed, when tlie sense of smell gradually returns. The occlusion is 
usually bilateral, but may exist ou one side onlj^ 

Double septum (duplication of the vomer), supernumerary turbinals, 
extension of the vomer back to the base of the skull and vertebral column, 
and teeth growing into the nares, usually incisors or canine teeth, are curi- 
osities which merely need mention. The congenital deficiencies in the 
nasal skeleton belong to the domain of harelip and cleft palate, and can 
be studied in works on general surgery. Congenital perforations, or 
almost entire absence of the cartilaginous septum, are occasionally found. 
]^arrowness of one nasal fossa is a common condition. This usually takes 
place in the posterior part, the septum and turbinals, especially the 
lower, approaching one another so that the choana is almost occluded. 
Septal deviations are doubtless in many cases congenital, but they and 
their effects will be considered in another chapter. Adhesions between 
the turbinals and deviated septum are quite common, and many of them 
are congenital. 

Treatment. — Congenital closure of the anterior nares must be opened 
by incisions, and the opening increased by the introduction of laminaria 
tents. Later it can be maintained by tubes or pieces of hollow bougies. 
The occlusions of the posterior nares must be opened at once in infants, 
as the obstruction to nasal respiration keeps the child from nursing. To 
accomj)lish this, a stout probe or the blunt end of Ingals's nasal bone- 
forceps should be pushed through the obstruction, the cutting edge of the 
latter being used if needed. In adults and older children the bony plate 
can be perforated in several places with the trephine, and the opening 
enlarged with the saw or nasal bone-forceps. A good procedure is to 
pierce the obstruction with a trocar during general anaesthesia, while the 
finger is placed in the nasoi)harynx as a guide. 

Adhesions between the lower turbinal and septum should be divided 
in such a manner that a space remains between the wounded surfaces 
after the operation. For this purpose Pynchon's or other punch-forceps, 
which excise a piece, are excellent. Electrolysis will also destroy the 
adhesion in such a manner that it will not reform. The apparatus and 
current strength to be employed are the same as those described under 
hypertrophic rhinitis. Simple division and keeping a foreign substance 
between the wound surfaces are tedious, and agglutination of the tissues 
is apt to recur as soon as this is removed. 

FRACTUEES OF THE NOSE. 

Fractures of the nose represent about one per cent, of the total of all 
fractures, and hence are among the rarer ones. 

Etiology. — Fractures of the nose are usually caused by falls or blows. 

Fatliology. — A common form of fracture is a transverse one of the 
nasal bones about their middle. In this case the lower fragment is 



CUTANEOUS DISEASES, DEFORMITIES, AND INJURIES OF THE NOSE. 291 

driven backward, forming an angle with the ui^i^er, that remains in 
place. As the nasal bones are sni^ported only in their upper two-thirds 
by the perpendicular plate of the ethmoid bone, and below this by the 
cartilaginous septum, the latter is driven backward with the fractured 
ends of the nasal bones, and is bent, broken, or dislocated from its groove 
in the vomer and the sui)erior maxillary ridge, or its anterior inferior 
angle is detached from its connection with the membranous septum. 
Another form of fracture or, more proi^erly, dislocation is longitudinal 
separation of the nasal bones from each other, or the lateral dislocation 
of both bones together from their attachment to the nasal processes of 
the sux)erior maxillary bones. 

In some cases the nasal bones are driven straight backward between 
the nasal processes of the sui^erior maxillary bones, and the resulting 
deformity is very characteristic. A deei^ groove i^resents where the 
nasal bones formerly were, marked on either side by the sharp ridge 
caused by the iDrojection of the nasal processes of the suiDcrior maxillary 
bones. In some cases the nasal ]3rocesses are also fractured and driven 
backward into the nasal cavity, so that the nose is almost effaced. Ex- 
treme violence, such as the kick of a horse, may produce comminuted and 
compound fractures of the nose of a most serious nature. A common 
form of this accident is fracture of the frontal bones at and above their 
junction with the nasal bones. In these cases the lower i^arts of the fore- 
head and nose are driven in and the frontal sinuses ex]30sed. A fatal 
result is common, as the cranial cavit}^ is usually opened. 

In fractures of the nose below the ui:)per thirds of the nasal bones, 
even if extensive and involving the perpendicular plate of the ethmoid 
bone, the cribriform x^late is not fractured, but in fractures above this 
point the cribriform plate and the roof of tlie orbit are generally broken. 
This alters the prognosis very unfavorably. 

Fractures of the septum require separate consideration. Except in 
cases of extreme destruction, the vomer is practically safe, and the per- 
pendicular plate of the ethmoid is fractured only when the upj)er half 
of the nasal bone is driven in, as its attachment does not extend below 
this. Therefore fractures of the bonj^ septum are rare. Those of the 
cartilaginous septum, on the other hand, are among the commonest of 
all nasal fractures, are most apt to accompany the breakage of the lower 
l^art of the nasal bones just described, and are usually found in ihe 
ui3per part of the cartilaginous septum, the fracture being generally of 
a longitudinal character. The septum may be the seat of an infraction 
and merely bent out on one side, or»the fragments may override and 
be pushed back on one another. In these cases a h?ematoma generally 
appears on each side of the septum, due to blood effused under the peri- 
chondrium and mucous membrane. 

Dislocation of the lower border of the cartilaginous septum from the 
sui^erior maxillary ridge and at times from the upper border of the vomer 



292 DISEASES OF THE NOSE AND NASOPHARYNX. 

is not uncommon. The dislocated edge of the cartilage presents as a 
whitish ridge of characteristic shai^e by the side of the anterior nasal 
spine and may narrow the corresponding naris greatly. In some cases 
merely the anterior inferior angle of the quadrangular cartilage is sepa- 
rated from the membranous septum. 

Symptoms. — iS'ose-bleed, varying from a few drops to serious hemor- 
rhage, accompanies ail forms of fracture of the nose. The deformities 
mentioned above can be seen only for a short time after the accident, as 
the swelling which supervenes, and which is due to the effused blood, 
appears promptly and is great. In most cases the nose is so embedded 
in swollen tissues that only its general direction can be noted, while its 
outlines are completely lost. The swelling often spreads to the cheeks 
and eyelids, causing the latter to puff out. The rapidity and extent of 
the tumefaction account for the frequency with which nasal deformities 
after fractures go unrecognized until union has occurred and it is too 
late to remedy them. Subcutaneous emphysema of the face may occur, 
especially when fractures involve the antrum or frontal sinus, being 
provoked by blowing of the nose to remove clots. Concussion of the 
brain does not occur in simple fracture of the nasal bones. The serious 
fractures mentioned, involving the frontal, nasal, and ethmoid bones, 
may be accompanied by fatal cerebral complications, due either to intra- 
cranial hemorrhage or to suppuration with x)urulent leptomeningitis, as 
in other compound fractures of the skull. Even when the cranial cavity 
is not opened, these grave compound fractures may cause sinus suppura- 
tion and necrosis of fragments, orbital phlegmons, and purulent menin- 
gitis, due to the propagation of the infection by means of the veins, 
especially the ophthalmic and ethmoidal veins. 

In fracture of the cartilaginous sej^tum the swelling is apt to take the 
form of hsematoma of the septum. In dislocation of the septal cartilage 
from the vomer, superior maxillary ridge, and membranous septum the 
nose below the nasal bones loses support, recedes, and its profile shows a 
depression at this point. This can be effaced by pulling the septum 
forward with forceps. 

Diag)wsis. — An early diagnosis is desirable, but not always possible, 
as the case may be seen when the swelling is fully developed. Here it is 
necessary to warn the patient that some deformity may remain after the 
swelling subsides, though all care be used in reducing the fracture. In 
these obscure cases an X-ray picture of the nasal skeleton should be 
taken, if possible. In addition to this, in all doubtful cases general anaes- 
thesia should be employed to make the diagnosis positive. Rhinoscopy 
is always to be used, as the cartilaginous septum is invariably fractured 
or displaced in all fractures of the nasal bones. 

Treatment. — Eeposition in cases of fracture of the nasal bones with 
infraction of the septum is best accomplished by seizing the tip of the 
nose firmly and pulling it forward, while introducing the little finger into 



CUTANEOUS DISEASES, DEFORMITIES, AND IXJUEIES OF THE XOSE. 293 

the narrowed naris and pressing the septum over with it. Once pulled 
back into place, the structures usually remain in position. In order to 
make sure of this, however, it is better in most cases to tami)on the nares 
with lint imiDregnated with bismuth subnitrate or iodol in the manner 
described under epistaxis. AVhen greater force is needed, the septum 
may also be i^ulled forward with forceps with flat, long blades which 
take hold of a large surface. The blades should have a small drainage- 
tube tightly slipped over them, so that the mucous membrane shall not 
be injured. AVhen the nasal bones have been displaced in the same di- 
rection, they can sometimes be put back by seizing them with the fingers 
and pushing them towards their normal seat. AVhen they will not yield, 
a strong probe or smooth rod, not more than one-eighth of an inch in di- 
ameter, is to be passed along the under surface of the nasal bones, and the 
latter lifted while being pressed back to i^lace with the fingers. A thicker 
instrument than the one mentioned cannot be passed into the narrow 
space between the septum and nasal process of the superior maxillaiy 
bone. The end of the probe is to be protected with a thin film of rubber 
in the manner mentioned above. The same instrument should be used to 
raise the nasal bones if displaced backward. The manipulation should 
be preceded by local anaesthesia with cocaine. A dislocated septum can 
be replaced by pulling it strongly forward with forceps and packing the 
nasal fossae to retain it in position. 

In fractures of the nose as usually seen, plugging of the nares is all 
that is needed to maintain the fragments in place, being far more effec- 
tive than any external sj^lint. It is also superior to the s^irings or tubes 
devised for use within the nostrils. In those cases, however, in which 
there is an obstinate tendency to lateral displacement of the nose, an ex- 
ternal splint of i^laster of Paris may be employed. In all difficult cases 
narcosis is imperative, as only with its aid can the nose be freely ma- 
nipulated for purposes of examination and replacement. If the frag- 
ments cannot otlierwise be reduced, there should be no hesitation in cut- 
ting down on the seat of fracture, exposing it over its whole extent, and 
replacing the broken bones with blunt or sharp hooks or forceps. The 
remaining scar will not mar the features as much as even a small deform- 
ity of the nasal skeleton. Union is usually rapid and without apprecia- 
ble callus. 



CHAPTEE YIL 

FIBRINOUS AND DIPHTHERITIC RHINITIS. 
FIBRINOUS RHINITIS. 
Synonymes. — Pseudo-membranous rhinitis, membranous rhinitis. 

Fibrinous rhinitis is an acute inflammation of the nasal mucous 
membrane characterized by great swelling and false membrane on its 
surface f this is firmly attached to the nasal mucosa. The disease is 
usually accompanied by slight constitutional symptoDis, takes a subacute 
or chronic course, and shows no tendency to spread to other parts. The 
false membrane forms again when removed, exposes a bleeding surface if 
torn away, and when it finally disappears leaves neither scars nor losses of 
substance. The swelling is usually so great that the affected nostril or 
nostrils are generally entirely occluded. The swollen mucosa has an oedem- 
atous look, and is seen to be normal in color or moderately congested, 
or sometimes even pale, when false membrane does not hide the tissues 
from view. The turbinals especially give the impression of a watery, 
somewhat translucent swelling. Microscopic examination shows the epi- 
thelium and submucous tissues to be densely infiltrated with leucocytes. 
The false membrane contains many micro-organisms, varying according 
to the case, the most constant being the Klebs-Loffler bacillus, strepto- 
cocci, staphylococci, and pneumococci. 

Etiology. — Though clinically a different disease from nasal diphtheria, 
modern observers have proved that almost invariably the Klebs-Lofiler 
bacillus is present, so that clinicians regard this microbe as the cause of 
the disease in by far the larger proportion of cases. The affection occurs 
almost exclusively in children, though adults have acquired it. 

Symrptoms. — The disease may begin as a common cold in the head, or 
be ushered in by fever, the symptoms being surprisingly mild. Beyond 
a watery discharge, becoming mucopurulent in about two weeks, and 
occlusion of one or both nostrils, there is generally so little constitutional 
disturbance that the children go to school or play as usual, the parents 
considering the matter an ordinary cold. The symjDtoms are not invari- 
ably so slight as this, however, as there may be fever for a week or two, 
and grown people have complained of great depression while the disease 
lasted. The membrane does not extend to the tonsils or pharynx, but 
remains confined to the nares. The chronic course of the disease — from 
six to eight weeks — usually leads the parents to seek medical advice. 
Inspection usually shows both nostrils involved in the disease, though 
294 



FIBRrXOUS AXD DIPHTHERITIC RHINITIS. 295 

the ailment may be unilateral. The nares are generally entirely closed 
by the swollen mucosa, which may be covered in part or completely 
with gelatinous fibrinous masses. Ordinarily the turbinals are so swollen 
that they lie in contact with the septum, so that only the anterior edge 
of the false membrane may be visible as a yellowish-white streak. In 
other cases the swollen lower turbinal projects so far forward that it 
looks like a tumor partly covered with a fibrinous coat. If picked 
off, the membrane is soon renewed. For a long time there is a ten- 
dency to crusting and i^urulent discharge, until the parts finally return 
to their normal state. The irritating secretions often excoriate the upper 
lil) and nostrils. 

Diagnosis. — Clinically, the disease offers a decidedly different picture 
from the classic cases of diphtheritic rhinitis ; in this there are severe 
constitutional disturbance, headache, weakness, fever, with profuse jDuru- 
lent discharge, often of a foul odor, and preceded for some days by serous, 
often sanguinolent, secretions. The chief characteristic of nasal diph- 
theria, however, is its tendency, unlike fibrinous rhinitis, to SjDread to 
the nasopharynx, tonsils, larynx, and trachea. Such cases are often not 
diagnosed until the spread of the disease explains the nasal symj)toms. 
Ehinitis fibrinosa is not followed, as is diphtheria, by nephritis or 
paralyses. The glands are not swollen in fibrinous rhinitis, while in 
diphtheria the submaxillary and cervical lymphatic glands are commonly 
involved. Fibrinous rhinitis is undoubtedly, in some cases, a mild form 
of nasal dii>htheria that may convey the disease in a severe form to 
others. For a pro^^er diagnosis cultures must alwaj'S be made. 

Prognosis. — Fibrinous rhinitis is generally of a benign nature, and 
runs its course in from four to eight weeks without complications. This, 
however, is not always the case, as diphtheritic symptoms have occa- 
sionally appeared late in the disease. 

Treatment. — As virulent Klebs-Loffler bacilli have often been found 
in the exudate, the patient should be isolated and precautions taken as 
in diphtheria. All nasal secretions should be collected in cloths, which 
are to be promptly burned. The child must not be allowed to associate 
with other children. Those who have been in intimate contact with 
it had better receive a prophylactic injection of from three to five hun- 
dred units of diphtheria antitoxin, provided cultures show the presence 
of Klebs-Loffler bacilli. In spite of the mild nature of the disease, it 
is better to give the patient an injection of one thousand units of anti' 
toxin at once, even before the results of cultures are known, as delay 
diminishes the effectiveness of the remedy, and it is desirable to bring 
the disease to a speedy end, as the patient is a menace to all about him. 
There is, however, not that urgency that exists in diphtheria, and. if it 
be preferred, there can be no serious objection to awaiting the results 
of culture experiments. 

In a case of two days' duration, seen by O. T. Freer, the membrane 



296 DISEASES OF THE NOSE AND NASOPHARYNX. 

disai)peare(l in Wo daj-s after antitoxin was injected 5 so that, consider- 
ing the nsnal chronic course of the disease, it is reasonable to suppose 
that the remedy acted efficiently. 

In small children but little can locally be done on account of their 
struggles. In older children and adults in the first days of the disease 
the intense swelling that closes the nose comxDletely makes local applica- 
tions impossible unless the nasal mucosa can be made to retract suffi- 
ciently by cocaine applications,'in which case iodol can be insufflated with 
benefit. No attemiDt should be made forcibly to remove the fibrinous 
masses, as it would denude the tissues of epithelium and so expose the 
blood- and lymph- vessels to the absor^^tion of toxins. 

Later, in the stage of suppuration, if there be much secretion this can 
be removed in the way described in the treatment of acute rhinitis. If 
it be possible to use it, irrigation with weak potassium permanganate 
solution, one-eighth of a grain to the ounce, will be most effective. 

For dissolving the crusts and dry scales apt to form in the nostrils 
towards the end of the disease oily sprays are to be used. The excoria- 
tion and eczematous patches prone to form on the upper lip and nostrils 
may be treated with benefit by an ointment containing ten grains of sali- 
cylic acid to one-half ounce each of lanolin and vaseline. 



DIPHTHERITIC RHINITIS. 

Diphtheritic rhinitis occurs in a primary and secondary form. Primary 
diphtheritic rhinitis has been considered in the article on fibrinous 
rhinitis. 

Secondary nasal diphtheria is consecutive to the usual form of the 
disease on the tonsils, uvula, and in the oropharynx. From these re- 
gions the diphtheritic process ascends to the choanse along the dorsum 
of the uvula and by way of the nasopharynx. Its appearance in the 
nose is preceded by the symptoms of acute rhinitis. Intense swelling 
of the mucous membrane of the nose follows this, and soon produces 
total occlusion of the nares. The secretion is at first mucous, but 
with the appearance of the false membrane it becomes thin, watery, 
and often sanious in character. The discharge irritates the nostrils 
and ui^per lip so that these soon present a red, swollen, and excoriated 
condition, and the excoriations may become the seat of diphtheritic 
membrane. Within the nares the false membrane may adhere so 
lightly in i)laces that pieces of it are cast off and blown from the 
nostrils, while in other places the membrane is firmly attached and may 
even penetrate the tissues beneath the epithelium. When this occurs, 
ulcerations remain after the membrane is cast off, and may lead to 
adhesions within the nares. Inspection may show yellowish-white 
masses of membrane protruding into the nasal vestibule. When these 
are removed the mucous membrane underneath is found red, swollen, and 



FIBRINOUS AND DIPHTHERITIC RHINITIS. 297 

bleeding. When the false membrane is loosely attached to the mucous 
surface and cast off, it is usually rapidh^ reproduced, aud this process 
may be relocated several times before it ceases to api^ear. In some cases 
fibrinous casts of an entire meatus are discharged from the nose. When 
the membrane penetrates the mucous surface deei^ly, it adheres until it is 
cast off by suppuration, leaving a granulating surface behind which may 
again become diphtheritic or heal over. As recovery begins the secretions 
lose their Avatery character and become purulent, ^ose-bleed occnrs 
with comparative frequency, and is usually of bad omen : in hemor- 
rhagic cases, with grave sym^^toms of septic or diphtheritic general 
toxaemia, it may prove fatal. If secondary infection with saprophj'tic 
germs be added to that due to the diphtheria bacillus, the membrane be- 
comes gangrenous, togetlier with the i^arts it has invaded. The false 
membrane softens, swells, becomes discolored and pasty, and when there 
is hemorrhagic transudate into it it may become black. The discharge 
acquires a fetid, cadaverous odor, while its intensely irritating proper- 
ties cause great redness, swelling, and excoriation of the ui^per lip and 
nostrils. The patients are apt to be somnolent, while the foul discharge 
runs freely from the nose and mouth. In many cases the system is over- 
wlielmed by the septic i^oison and death ensues. In those cases which 
recover the gangrenous portion of the mucosa is cast off as a slough, 
but the defects left in the mucous surface after this process are fre- 
quently surprisingly insignificant considering the gravity of the inflam- 
mation. 

The gangrenous processes in the mucosa may also be due to the great 
depth of the diphtheritic infiltration, which shuts off the blood-supply 
from portions of the mucous membrane. In these cases, in i^laces in 
which the nasal surface is uncovered by false membrane it jDresents a 
livid red appearance. Hemorrhages also occur into the mucous mem- 
brane and beneath the false membrane on account of the stagnation of 
circulation. The dead tissue becomes putrid and the nasal discharges 
acquire a foul odor. The granulating surfaces left after the slough has 
been cast off may form adhesions between different portions of tlie nasal 
interior, chiefly the septum and turbinals. 

When secondary diphtheria attacks the nose almost at the same time 
that it makes its ai^pearance in the fauces, experience shows that the 
case is likely to be one of great gravity. Xasal diphtheria is apt to 
take a more tedious course than diphtheria in the pharynx, lasting nor- 
mally about three weeks, though cases of six weeks and longer are not 
rare. 

Dii)htheria may have its inception in the choanse and spread thence 
to the nares and pharynx. Diphtheria of the nose secondary to dii)h- 
theria of the pharynx presents no difficulties in diagnosis. In primary 
diphtheria of the nose a diagnosis is to be made from those cases of 
membranous rhinitis due to streptococci, staphylococci, and pneumococci, 



298 DISEASES OF THE NOSE AND NASOPHARYNX. 

and cultures from the membrane are needed to determine the presence of 
the Klebs-Loffler bacillus. 

Treatment. — Of first importance is prompt treatment by diphtheria 
antitoxin, as mentioned in the treatment of fibrinous rhinitis. Syr- 
inging the nose in little children in the manner described under acute 
rhinitis, and irrigations in older ones, may be needed to cleanse the 
nares of false membrane when this is loose and to remove pus. Potas- 
sium permanganate in the strength of one grain to the ounce may be 
recommended for this purpose. A powder consisting of three parts of 
iodol and one part of papain may be insufflated with advantage. 



CHAPTEE YIIL 

CHROXIC RHIXITIS, SIMPLE AND IXTUMESCEXT. 

SjTDOnymes. — Rhinitis chronica, chronic catarrh, chronic coryza. 

' The term chronic rhinitis embraces chronic inflammation of the 
nasal mucous membrane and its results, hypertrox3hy and atrophy, ^rhich 
may outlast the inflammatory process. It is characterized by moderate 
or excessive discharge from the nose, or by absence of all discharge, or 
by drying of the secretions within the nasal cavities in the form of crusts. 
The mucous membrane maj' be of normal thickness, or merely subject to 
intumescence capable of temporary disappearance, or it may be in a 
state of more or less complete atrophy, or in a permanently thickened 
and hypertropliied state. Thus the capacity of the nose for the passage 
of air may vary from nearlj^ complete obstruction to abnormal roominess. 
Chronic rhinitis, therefore, offers sucli extremes of difference, as regards 
symj^toms, that observation has taught that the varying aspects of the 
disease are parts of the same process. The widel}^ differing states 
presented by chronic rhinitis have made it customary to divide its de- 
scription into four varieties, though the fact is understood that, with the 
exception of atrophic rhinitis, these varieties are all in relation to one 
another as stages of the same general disease process, and that they merge 
insensiblj" one into the other as this progresses. The most recent inves- 
tigations have made the connection of atrophic rhinitis with the other 
forms of chronic rhinitis doubtful in many cases. 

The four varieties of chronic rhinitis to be considered are simple 
chronic rhinitis, intumescent rhinitis, hypertrophic rhinitis, and atrophic 
rhinitis. 

Etiology of Chronic Bhinitis. — As the etiolog^^ of the first three varieties 
of the disease is the same, their causes will be described together, while 
those of atrophic rhinitis will be considered separately. 

Anything that keeps the nasal mucous membrane in a state of per- 
sistent irritation may lead to chronic rhinitis. The traumatism to the 
mucous surface due to the inhalation of substances chemically or me- 
chanically damaging to the delicate ei^ithelium of the nasal passages, 
if continuous or often repeated, is apt to lead to chronic rhinitis. The 
same is true of frequent colds in the head. The anatomical changes 
created hy these have not time to be removed before a fresh attack 
replaces them and the local circulation has been so much deranged that 
a return to the normal state becomes impossible. At the same time 
metaplasias of the epithelium occur which cannot readily be restored, 
so that the frequent action of pernicious agents at last creates, as it 

299 



300 DISEASES OF THE NOSE AND NASOPHARYNX. 

were, a new mucous membrane differing histologically from the normal 
state, and one that will not return to this even if the causes of the dis- 
ease originally active cease to be oi)erative. Chronic rhinitis is to some 
extent an occupation disease, as millers, stonecutters, and those engaged 
in the multitudinous occupations in which dust abounds in close rooms 
are liable to it. Workers in chemicals (sulphuric acid, potassium bi- 
chromate, arsenic, phosphorus) are subject to the disease, while those 
exposed to the hardships of outdoor weather and cold winds seem to 
acquire immunity from rather than a tendency to chronic coryza. As 
all people exposed to the causes mentioned do not suffer from chronic 
rhinitis, it seems that a predisposition, either general or local, is needful 
to develop the disease. General i)redisposing causes are debility and 
lowered vitality, inactive life, relaxation due to life indoors, lack of 
fresh air, and venous congestions caused by stooping over desks or 
work-benches. Mercury has been accused of rendering those using 
the drug suscej)tible to chronic coryza, chronic rhinitis following the 
use of the iodides is at least rare, and it is probable that so-called 
scrofula is a sequela of acute and chronic coryza rather than a j^redis- 
posing cause. 

Local causes are all things narrowing or occluding the nasal passages, 
as ecchondroses, exostoses, sei^tal deviations, and excessive size of the 
turbinated bones. These may lead to chronic rhinitis, but usually to the 
intumescent rather than the simple chronic or hypertrophic form. The 
effect of nasal obstructions is to make it difficult to remove the nasal se- 
cretions, and the excessive rarefaction of the air back of them during 
insi^iration favors venous stagnation. Though hypertrophies of the fau- 
cial and pharyngeal tonsils are alleged causes of chronic rhinitis, it 
is rarely associated with such conditions. Postnasal catarrh is to be 
considered as coexisting with chronic rhinitis rathej than as causing 
it. Chronic coryza is symptomatic of sinus disease, caries of the nasal 
skeleton, or the presence of foreign bodies. As Hajek states, bacteria 
play but a secondary role in the causation of chronic coryza. Children 
are predisposed to simple chronic rhinitis, especially the purulent form, 
and the child with the chronically running nose is familiar to all. With 
the exception of the atrophic variety, men are more liable to chronic 
rhinitis than women, occujDation having doubtless an influence on this 
malady. 

SIMPLE CHRONIC RHINITIS. 

Simple chronic rhinitis is a catarrhal inflammation of the mucous 
membrane attended by little swelling and characterized generally by great 
irritability and susceptibility to acute exacerbations. It is attended by 
congestion and by watery mucopurulent or purulent secretions, which 
may be excessive. The mucous membrane is evenly and moderately 
swollen and reddened, but at times the turbinals show more swelling than 



CHROXrC RHINITIS, SIMPLE AND INTUMESCENT. 301 

the rest of tlie surface of the nasal passages, the swelling having a hyper- 
semic character onlj^. A good deal of secretion, either simply mucous 
in character or mucopurulent, is found in the nose, and in the purulent 
forms, pus. Ulceration is absent, but erosions may be i)resent, and 
crusts are apt to form at the nasal entrance and on the anterior part 
of the nasal septum. Eemoval of these with the finger-nail is sometimes 
the cause of ulceration, and finally of perforation of the cartilaginous 
septum. Microscopically, the epithelium and subepithelial tissues are 
found infiltrated with round cells, which collect esi^ecially about the 
glands and vessels. The laj^ers of epithelium are increased in number, 
the upx^er layer of cells becoming cuboid or flattened into pavement 
epithelial cells, while islands of normal ciliated epithelium are found 
between the areas of epithelial metaplasia. 

Symptoms. — The patient experiences itching, burning, and tickling 
sensations in the nose, sneezing usually occurs on the slightest provo- 
cation, while headaches and pain in the eyes are frequent symi^toms. 
^Rot infrequently there are loss of the sense of smell and partial deafness, 
the sense of taste may be obtunded, and profuse lachrymation sometimes 
occurs. ^N'asal resi^iration is not obstructed except by the accumulation 
of secretions, especiallj' if these dry at the entrance of the nostrils. 

The quantity of nasal secretion varies from a slight increase above 
the normal to large quantities of watery discharge causing great dis- 
comfort. In other cases the nasal secretion is mucopurulent and at 
times purulent, and there is a tendency for the secretions to dry and 
crust in the anterior i^art of the nose. Inspection shows the entire 
mucous membrane evenly swollen and red, but rarely is there enough 
swelling to cause obstruction to breathing, which depends chiefly on the 
accumulation of secretions. After the disease has lasted some time the 
metaplasia and thickening of the epithelium give a whitish color to the 
surface. 

Diagnosis. — The diagnosis is difficult only in cases with purulent se- 
cretion, as here disease of the sinuses, especial h^ of the sphenoidal sinus 
and ethmoidal labyrinth, may have to be excluded. In sinus disease the 
discharge is usuall}- unilateral and very often fetid. The ordinary forms 
of simple chronic rhinitis can be diagnosed by insi3ection and from 
the history. When there is a free watery discharge hay fever may be 
suspected, but this occurs only at certain seasons of the year, and is 
usually accomx^anied \}\ marked tumefaction of the mucous membrane 
of the turbinals. In little children with purulent rhinitis syringing must 
precede inspection for purjDOses of diagnosis, or the Politzer inflation-bag 
may be used to blow the secretion from the nostrils, care being taken that 
the nostril not used for the insertion of the olive-shaped tip of the air-bag 
be left open for the exit of secretions, otherwise the surgeon is liable to 
force pus into the middle ears and establish an otitis media. The method 
of syringing is described under treatment of acute rhinitis. As the 



302 DISEASES OF THE NOSE AND NASOPHARYNX. 

accessory sinuses are but little developed in children np to the period of 
second dentition, sinus disease can practically be excluded in them up to 
that time. This is an aid in diagnosis, as i)urulent rhinitis is commonest 
in children and examination most difficult. 

Prognosis. — The affection runs a tedious course, sometimes lasting for 
many years. Though some cases eventually recover spontaneously, others 
go on from bad to worse, and finally terminate in some of the other 
forms of chronic nasal catarrh. The simple form of chronic rhinitis may 
become purulent on account of secondary infection with pyogenic germs, 
this being most apt to occur in children. Acute blennorrheic catarrh 
of the nose, if neglected, may result in chronic rhinitis with purulent 
secretion. 

Treatment. — The avoidance as far as possible of those conditions pro- 
ducing chronic rhinitis and mentioned in the etiology of the disease is 
the first essential. Chronic rhinitis so often depends on a low state of 
the general health, due to underfeeding, digestive disorders, and sluggish 
habits of body producing venous stagnations, that only the physician 
well versed in the treatment of the general disorders of the body can 
efficiently treat it. 

For the local treatment the indications are to remove irritating dis- 
charge, to diminish its production, to disinfect the nose if the secretion be 
purulent or offensive, and to remove crusted material. When the dis- 
charge is free and watery, it needs no washing for its removal, but when 
it is thicker, irrigations or sprays are needed. Watery sprays are quite 
sufficient for cases in which the discharge is moderate in quantity and 
fairly fluid, but when it is thick and purulent or mucopurulent, irrigation 
is needed. The nasal douche involves the danger of water's* entering the 
middle ear and carrying infectious material with it, thus causing suppu- 
rative otitis media. The nasal douche washes chiefly the lower meatus 
and floor of the nose, leaving the upper portion of the latter and the 
nasopharyngeal vault uncleansed. The hard-rubber irrigating tube (Fig. 
102) mentioned under treatment of acute rhinitis is efficient and safe, and 
will free the recesses of the nose, its upper passages, and the vault of the 
pharynx of foreign matter, and it may be given to the patient to use. 

The removal of drying or crusting material is best accomplished with 
the aid of oily substances, and when there are crusts to wash away it 
is a very essential preliminary to oil the nasal passages an hour or so 
beforehand, as the oil dissolves crusts and tough glue-like masses of 
secretion. Oleum ]3etrolatum album or vaseline may be sprayed into the 
nose^ or fluid vaseline may be used in a metal atomizer designed for 
heating these materials, or be applied with a common sewing-machine 
oiler. For cleansing purposes oil may also be dropi)ed into the nostrils 
with a medicine drojjper, or the mucous membrane may be painted 
as far back as possible with vaseline applied with an artist's small 
paint-brush on a long, slender handle. Oil has a tendency to spread. 



CHRONIC RHINITIS, SIMPLE AND INTUMESCENT. 303 

SO that a small quantity will soon extend over a large surface. The 
thick oils will stay longest in contact, and are therefore preferable for 
dissolving crusts. 

As a disinfectant wash a solution of potassium permanganate is the 
cheaiDCSt and most efficient. It acts in the weakest solutions, which 
makes it possible to use it without irritating the mucous membrane, 
while the ordinary antisei^tics, such as carbolic acid, resorcin, or the 
many proprietary compounds of antisei)tics, to be efficient have to be 
used in such strength that their employment is injurious and unendurable 
to the sensitive nasal mucous membrane. Hydrogen dioxide, while simi- 
lar in action to potassium i^ermanganate, does not seem to be as efficient 
as the latter in a solution of one or two grains to the i^int of water. 

The number of remedies employed to diminish the quantity of nasal 
secretion emphasizes the difficulty of such a task. The first class of 
remedies to be considered includes the astringents. The mucous surface 
of the internal nose is so very sensitive that the weak strength in which 
these have to be employed i^robably accounts for their ineffectiveness 
in chronic rhinitis. The zinc salts and alum have a reputation for 
doing permanent injury to the sense of smell. In some rare cases the 
astringents are of benefit. Good examj^les are silver nitrate, one grain 
to the ounce of distilled water, and copper sulphate, three graius to the 
ounce of water. When they are of benefit the astringents do good by 
creating active hypersemia, which causes the absorption of inflamma- 
tory exudates in the mucous tissues and reduces the irritability of the 
mucous membrane. The astringents should be used in spray form. An 
oily spray of from ten to twenty grains of terebene to the ounce of 
oleum petrolatum album is one of the most efficient local applications. 

Powders blown into the nasal cavity are often useful, Bresgen having 
recommended pure sodium sozoiodolate as a powder that rapidly dimin- 
ishes secretion. A sedative powder consisting of from five to ten per 
cent, of boric acid, twenty-five per cent, of iodol, five per cent, of starch, 
and enough sugar of milk to make one hundred grains, with occasionally 
one per cent, of cocaine, may be found of much benefit. 

F. Klemx:)erer recommends iodi puri, 1 ; jDotassii iodidi, 2 ; glycerini, 
20, as a i^igment to be painted on the mucous surface. Pure boric acid 
or bismuth, in powder, is at times efficient. 

Before any local application can be of benefit the nasal i^assages 
must be freed from secretion. Certain patients in whom there is marked 
hypertesthesia of the nasal mucous membrane, upon going into the 
wind or dust are subject to attacks of sneezing accompanied by excessive 
secretion, necessitating almost constant use of the handkerchief. There 
is consequently soreness of the nose, the source of much annoyance. 
This is a most obstinate variety of simple chronic rhinitis, but fortu- 
nately it is rare. In searching for the sensitive spots in these cases, a 
probe should be passed to the back part of the nasal cavity and drawn 



304 DISEASES OF THE KOSE AND NASOPHARYNX. 

forward over the various parts of the mucous membrane 5 as a sensi- 
tive si^ot is touched, the patient winces from the pain or inclination 
to sneeze or cough, and sometimes says that the probe pricks or burns. 
The most efi&cient treatment is superficial cauterization of the sensitive 
areas, as practised in the treatment of hay fever. Sedative powders and 
sprays should be used in the intervals between the cauterizations, which 
should not be made oftener than once in from five to seven days. The 
cauterizations destroy the terminal fibres of the hypersensitive nerve, 
but are not deep enough to destroy the mucous membrane. 

INTUMESCENT RHINITIS. 

As there is a vasomotor form of acute coryza with swelling due to 
dilatation of the lacunar veins of the erectile tissue of the turbinals, as, 
for example, hay fever, rose cold, etc., so j^here is a chronic form of this 
condition which might be called coryza vasomotoria chronica, but which 
is known as intumescent rhinitis. Its characteristic is a persistent ten- 
dency to tumefaction of the inferior and often the middle turbinals, and 
occasionally the tuberculum septi. These swellings are often unilateral, 
and may change from one side to the other or temporarily disaj^pear. 

Patliology. — The i^athological changes are those of simple chronic 
rhinitis just described, bui in addition there are localized swellings, 
chiefly of the inferior and often also of the middle turbinals, the result 
of a paretic state of the muscular elements of these structures and of the 
muscular walls of their cavernous veins, which remain in a chronically 
distended condition. In intumescent rhinitis there is usually but little 
excess of discharge, though occasionally it is great, and presents the 
variations described under simple chronic rhinitis. As in simi)le chronic 
rhinitis, the pharynx and larynx are apt to be found in a catarrhal state, 
especially if the intumescence be sufficient to cause mouth-breathing. 

Symptoms. — The symptoms of intamescent rhinitis differ from those 
of simple chronic rhinitis chiefly in the predominance of nervous phe- 
nomena due to an exaggerated sensibility of the sensory nerves of the 
nose not generally found in the simjDle forms of the disease. The local 
symptom caused by the irritation of the sensory nerve-ends in the nose is 
a reflex paresis of the muscular coats of the lacunar veins and the mus- 
cular elements of the mucous membrane of the turbinals and portions 
of the septum. This results in venous stasis and hyi)er8emic swelling of 
these parts, so that the patient's chief complaint is of obstruction to 
breathing through the nose. This obstruction may be unilateral or it 
may occlude both sides of the nose. It fluctuates, being so slight at 
times as to cause only a little annoyance, or so great at others as to stop 
nasal breathing altogether. Fear of an examination or the touch of a 
probe may cause the unstriped muscle-fibres of the turbinals to contract 
and the swelling to recede at once. At night the swelling is aj^t to 
be worse, as the shallow breathing of sleep and the recumbent posture 



CHRON^IC RHI^^ITIS, SIMPLE AXD INTUMESCEXT. 305 

favor venous congestions of the head, so that these patients often lie with 
their mouths open and snore. Deep, full respirations through the nose 
have the tendency to relieve venous congestions, and therefore deei) in- 
spiration Trith the head thrown back is one of the means of relieving 
nose-bleed. The chest drawing in air through the comparatively narrow 
orifice of the nose has a reserve of negative j)ressure to spare, which is 
used to draw blood into the vessels of the lungs from the veins. ^Mien 
one breathes through the mouth, the air rushing into the lungs through 
its wide orifice enters without resistance, so that there is no reserve suc- 
tion force left for the aspiration of l)lood from the veins into the chest 
cavitj'. It can be seen from this that moutli-breathing establishes a 
vicious circle by favoring venous stagnations in the nose. The nasal ob- 
struction makes sleep restless and disturbed by dreams, so that the patient 
wakes uj) unre freshed and often with a headache. Sudden changes of 
temi)erature, as in going from a cold to a hot room or the reverse, will 
result in a sneezing fit with sudden nasal occlusion. Though the inha- 
lation of cold air will sometimes add to the swelling, usually this act 
will clear the nostrils, while the vigorous contraction of the unstriped 
fibres of the skin caused by a cold shower is generally accomi:)anied by a 
similar retraction of the nasal mucous surface with temporary relief 

The second nervous phenomenon accompanying intumescent rhinitis 
is sneezing. This is so easily aroused that even stepping into a bright 
light may excite this reflex through the unusual channel of the oi)tic 
nerves. All things which irritate the nerve-ends of the nasal mucous 
membrane will often give rise to i^aroxysms of sneezing. 

The third nervous symptom referable to this disease is pain. In the 
nose itself feelings of fulness, dryness, or stuffiness take the place of 
this symptom, but the irritated condition of tlie nasal uuicous surface 
will cause reflected x>ain to be felt in neighboring nerves, such as neu- 
ralgia in the region of the distribution of the sui^ra- orbital nerve and in 
the temples or in the occipital region, or there may be hemicrania accom- 
panying diseased conditions of the upper parts of the nose. Bresgen has 
recorded cases in which pain in the arms or chest disapi)eared as a result 
of treatment of intumescent chronic rhinitis. It is not to be suj^posed 
tliat these neuralgias are frequent accompaniments of intumescent rhinitis ; 
on the contrary, they are very rare conditions. 

The fourth group of nerve symptoms is referable to the cerebrum. 
Patients complain of heaviness, dulness, or inability to couceutrate the 
mind (aprosexia), with loss of memory. Xightmares and restless sleep 
are also common accompaniments of intumescent rhinitis. 

Distant reflexes are to be viewed with scepticism. Asthma often 
coexists with intumescent rhinitis, but only when it disappears as a re- 
sult of treatment of this is it to be regarded as dependent on the rhinitis. 
The same is true of spasmodic cough and spasm of the larynx. The 
eye is such a near neighbor to the nose that it is not surprising that ocular 

20 



306 DISEASES OF THE NOSE AND NASOPHARYNX. 

phenomena frequently attend intumescent rhinitis. Lachrymation and 
photophobia of reflex origin may be constant sources of complaint. 

The nasopharynx is nearly always involved in intumescent rhinitis j 
in fact, it is the seat of some of the most annojang symptoms. The 
nasal discharges, stagnating on account of the deficient air- current, are 
prone to flow backward at night and collect on the pharyngeal vault, 
where they dry, and are removed only by much hawking in the morn- 
ing, sometimes forming a crust that adheres for several days. As in 
simple chronic rhinitis, crusts are apt to form in the anterior part of 
the nasal passages, and at times their removal gives rise to nose-bleed. 
The irritating discharge causes eczema of the upper lip and rim of the 
nostrils, with fissures which are sometimes the source of erysipelatous 
infection. An occasional mortifying accompaniment of intumescent 
rhinitis is redness of the external nose, said by some to be a vasomotor 
disturbance. 

Laryngitis is a frequent complication of rhinitis intumescens. It may 
be due to extension of the disease downward from the nasopharynx, or to 
the strain the larynx is subjected to in its endeavors to overcome the 
stoppage of the vocal sound-waves by the obstructed nose. Even if 
there be no actual laryngitis the voice soon tires, especially in singing. 
Its alteration varies from a slight deadening, noticed, perhaps, only by 
the patient, to the thick nasal voice of the mouth-breather, with com- 
plete obstruction of the nares. The secretion in intumescent rhinitis 
presents all the variations described in simple chronic rhinitis. It may 
be free, watery, i^urulent, or mucoxDurulent, or it may be very slight, 
swelling of the turbinals being the only sign of the disease. The same 
case at different times will vary much in regard to the discharge, as 
all these patients are subject to frequent exacerbations which they call 
fresh colds. In the intervals little remains of the disease but the oc- 
clusion due to the intumescence, while during the colds the discharge 
goes through the variations described under acute rhinitis. The mucous 
membrane is usually congested, and one or both nasal cavities are foiind 
to be from one-third to two-thirds closed by swelling of the inferior tur- 
binated bodies. The swelling is not confined to the turbinals, but also 
often involves the region of the tuberculum septi situated opposite the 
anterior end of the middle turbinal and the sides of the vomer, as seen 
from behind by posterior rhinoscopy. The swollen membrane in the 
region of the tuberculum septi is usuallj^ of a slightly deeper hue than 
normal 5 that seen with the rhinoscoi)e at the posterior border of the 
septum is of a grayish color. The posterior ends of the inferior or mid- 
dle turbinated bodies sometimes appear much swollen and of a grayish 
hue 5 but this is more commonly present in hypertrophic rhinitis. By 
examination with the probe exquisitely sensitive spots are frequently 
found, irritation of which is apt to excite sneezing. Peculiarities of 
the swellings are that a probe will sink into them as if they were air- 



CHROXIC RHINITIS, SIMPLE AND INTTJMESCENT. 307 

cushions until it reaches the bone and that they will generally nearly 
disappear under the influence of cocaine applications. The swellings 
will sometimes decrease as the result of exercise, the venous congestion 
being relieved by the deep inspirations. Fear or pain caused by the 
touch of the probe may cause them to retract ; this, however, may 
have the reverse effect and increase the swellings. Posterior rhinoscoiDy 
will often show a mass of thick pus or a crust on the vault of the naso- 
pharynx. The nares may be free from secretion ; in fact, in the intervals 
between colds this is usually the case. 

Diagnosis. — The affection is to be distinguished from simple chronic 
rhinitis, from hyi)ertrophic rhinitis, and from nasal mucous polypi. In- 
tumescent rhinitis is to be diagnosed from simj)le chronic rhinitis by 
the absence of swelling in the latter. If the nasal passages be found 
free and yet there be a history of repeated obstruction, the patient must 
be told to return, so that his nose can be examined when the occlusion 
is present, as the obstruction complained of might have been due to 
retained secretion. In hypertroi)hic rhinitis the swelling will perhaps be 
uninfluenced by cocaine or disax)pear only in part. The swelling is apt 
to have an uneven, nodular appearance in the hypertrophic form of 
chronic rhinitis, and there is also permanent and not intermittent nasal 
obstruction. Only the inexperienced could mistake nasal mucous polypi 
for intumescent rhinitis. Their mobility, translucence, and the facts that 
a probe will move them back and forth, and that it can be passed on 
either side of them, are sufficient guides in the diagnosis ; furthermore, 
cocaine has no effect on the size of a x^olj^^us. 

Frognosls. — If untreated, the vascular swellings of intumescent rhi- 
nitis are liable in time to become true tissue hyperplasias and result in 
hyi3ertroi)hic rhinitis. This is not always the case, however, and the 
disease may go on for years with little change, and in some rare cases 
may end in recovery. The complications alter the prognosis and are 
more serious than the disease itself. As long as this lasts the deafness, if 
it exist, cannot improve, and often grows progressively" worse. Under 
the same conditions the laryngeal comj)lications tend to become invet- 
erate, while the voice of a singer may be ruined by the j)ersistent strain 
to which it is subjected in the effort to overcome the nasal obstruction 
to sound. Treatment alters the prognosis favorably so far as the nasal 
occlusion is concerned, and this can often permanently be removed. 
Whether the underlying chronic rhinitis will disappear depends 
much on its course and severity. The general health will usually 
markedly improve when the nasal obstruction is relieved. Sleep is no 
longer disturbed, nasal breathing is resumed and is an aid to the circu- 
lation, while the many nervous symptoms accompanying the ailment 
cease to exist. 

Treatment — All things inducing exhaustion and irritation of the 
nerves are to be especially avoided. The tone of the vascular system 



308 DISEASES OF THE NOSE AND NASOPHARYNX. 

must be sustained by means of cold shower-baths and calisthenics, or 
preferably out-of-door exercises. Mouth-breathing is seldom merely a 
bad habit, but is almost always due to nasal obstruction. As it favors 
increase of the nasal tumefaction, ]>ersistent efforts to use the nose for 
breathing will counteract the bad influence of oral respiration and 
tend to clear the nose and prevent the more severe forms of swelling 
of the turbinals. Of course, these efforts are available only when the 
nose is partly open for breathing. In the same way sedentary habits and 
shallow breathing favor passive nasal hypersemia, while active exercise 
with deep inspirations relieves it. Dust and nasal irritants are to be 
avoided, if j)ossible, and in cases in which the disease already exists, 
cold shower-baths are especially to be recommended. Under their influ- 
ence the erectile tissue of the turbinals contracts physiologically and the 
nose becomes free for breathing. 

Local Treatment. — It is necessary that marked obstructions due to 
septal deflections or protuberances should be removed before successful 
treatment of the disease can be exioected. In the earlier stages of the 
affection mild stimulating applications are indicated. These maj" be 
made two or three times a week, and consist of aqueous solutions of zinc 
sulphate, carbolic acid, and zinc chloride of sufficient strength to cause 
smarting or discomfort for not more than ten minutes. A good formula 
is— R Acidi tartarici, gr. i ; acidi carbolici, gr. ii ; acidi borici, gr. x 5 
zinci sulph., gr. iii ; aqute destil., 5i. M. Aqueous solutions may be 
employed for home use two or three times daily, such as boric acid, ten 
grains to the fluidounce, or sodium bicarbonate and biborate, of each 
from one and one-half to two grains to the fluidounce, or distilled extract 
of hamamelis or of pinus canadensis, from thirty to fifty minims to the 
fluidounce of water. A saturated solution of boric acid in camphor- water 
is also a useful soothing application. Oily x)reparations, such as oleum 
petrolatum album, containing camphor from one to two grains, menthol 
from one-half to one grain, oil of cloves from three to five minims, or 
terebene from eight to twelve minims to the fluidounce, are generally 
more beneficial than aqueous solutions. The oleaginous liquid alone 
may be used as a soothing application to x^revent the contact of irritating 
substances with the mucous membrane. 

When demanded, the nasal secretions must be removed in the manner 
described under simple chronic rhinitis, and one cannot hope to accom- 
plish much unless all viscid or crusting material is removed from both 
nose and nasopharynx. When the discharge is purulent or offensive a 
solution of potassium permanganate, one-eighth of a grain to the ounce, 
is indicated as a wash, but when thick, tenacious mucus has to be re- 
moved alkaline washes are best, or solutions of common salt. 

Intumescent rhinitis is a disease that is especially liable to lead 
patients into the cocaine habit, the relief given by the drug being so 
delightful that the temptation to its abuse is great. The continued local 



CHRONIC RHINITIS, SIMPLE AND INTUMESCENT. 



309 



use of cocaine is followed by a paretic state of the muscular coats of the 
veins of the cavernous tissue of the turbinals, and thus the drug adds to 
the disease. Cocaine should never be used continuously, but during the 
exacerbations of the disease its employment cannot always be avoided. If 
l^ossible, it should be em^Dloyed only at night to establish free nasal res- 
piration, so that sleep may be obtained. A solution of from one to two 
2Tains of cocaine to the ounce of saturated solution of boric acid is 
suificiently strong for a spray, of which onlj' a few drops are to be blown 
into each nostril. Cocaine may convenientlj^ be employed in the form 
of the following powder: sodii bicarbonatis, sodii biboratis, aa gr. iss; 
magnes. carb. levis, gr. iii 5 cocainte muriatis, gr. iv ; sacchari lactis, q.s. 
ad gr. c. This may be blown into the obstructed nostril two or three 
times in twenty-four hours in quantities not to exceed one-thirtieth of 
a grain of cocaine at a dose. For the application of powders to the nares, 
a serviceable instru- 
ment to give i)atients 
to use is a short glass 
tube about four milli- 
metres in internal di- 
ameter and four inches 
in length, flattened 
and expanded at one 
end but round at the 
other. 

It has been found 
that an extract of the 
adrenal glands has a 
similar effect to cocaine in reducing the congestion and swelling of the tur- 
binated bodies and in contracting the small blood-vessels. An aqueous 
extract, which is used as a spray to the nose four or five times a day, is 
the most satisfactory. The formula used is adrenals (desiccated), one 
drachm : boric acid, sixteen grains ; camphor- water (hot), one ounce ; dis- 
tilled water (hot), enough to make two ounces. Macerate for four hours, 
then filter. This makes a solution that retains its properties and does 
not decomj)ose for weeks. The sprays may be applied by means of any 
suitable atomizer. In fully develoj^ed cases of intumescent rhinitis the 
methods mentioned are but palliative, and only to be employed in those 
who will not consent to more radical ones. It is not necessary, on the 
other hand, to cauterize every temj)orary intumescence of the turbinals, 
and the slighter and not inveterate forms of the disease may be relieved 
by the general and local measures mentioned. The radical treatment of 
intumescent rhinitis consists in destruction of a portion of the swollen 
tissues by the gal vano- cautery or by chemical agents, or by removal of as 
much of the swollen mucous membrane as can be seized in the loop of 
the cold snare. 




Powder-blower. Tliree glass tuljes (one-third natural size). 
Straight tube for nasal, bent tubes for nasopharyngeal or laryngeal 
aiiplications. 




310 DISEASES OF THE NOSE AND NASOPHARYNX. 

Cauterization by Acids. — In the days when gal vano- cautery apparatus 
was cumbersome and expensive the use of chemical agents for nasal 
cauterization had its reason, but now they have been almost completely 
supplanted by the gal vano- cautery. , If an acid be used as a cautery , 
chromic acid is to be preferred. A few crystals of it on the end of a 
flat aluminum probe should be held over a flame till the acid fuses, 
then this should be allowed to cool. The fused acid is then rubbed 
over the part to be cauterized, which turns brown, and is at once to be 
sprayed with an alkaline solution. K'o more acid than will make the 

bulk of four or five pin-heads 
Fig. 107. should be used. It should be 

applied along a strip of mem- 
brane one -eighth of an inch 
wide and from one -half to 

Flat nasal probe (two-fifths natural size). Made of aliimi- i. ^ • 1 

num and bent at an angle of thirty-five degrees. turee-quartcrS 01 ail lUCn 

long. The cauterization may 
be repeated, if needed, in from ten to twenty days, when the parts have 
healed. 

Cauterization by chromic acid is followed by a sore that takes longer 
to heal than that after the gal vano- cautery ; there is also more pain to be 
endured afterwards and more discharge, while the results are not as cer- 
tain and the depth of the cauterization cannot be so accurately controlled. 

Galvano- Cautery. — In using the galvano-cautery an electrode with a 
blade about five-eighths of an inch in length, consisting of Ko. 21 platinum 
wire, should be employed. The iDart to be cauterized is first anaesthetized 
with a solution of atropine, one-tenth grain 5 strophanthin, one-fifth grain ; 
oil of cloves, three minims ; carbolic acid, ten grains ) cocaine uiuriate, 
twenty grains ; enough water to make one ounce ; applied with a small 
cotton swab. When angesthesia is complete the mucous membrane is 
usually retracted close to the bone and the operation is entirely i)ainless. 
The wire should become white in two seconds after closing the circuit. 
Speedy heating makes the wire cut too rapidly and causes bleeding, 
while a cherry-red heat makes it cut too slowly and gives the heat 
time to cook the surrounding tissues ^dth consequent severe reaction. 
Oiling the nose with vaseline makes its introduction easier. To deter- 
mine the depth to which the electrode should penetrate in order to reach 
the posterior end of the inferior turbinal, a Eustachian catheter may be 
passed in and hooked over the posterior border of the septum. Seizing 
this close to the end of the nose before withdrawing it, and retaining the 
hold obtained with the fingers, one can use the catheter as a measure of 
the depth to which the electrode should penetrate in order to cauterize 
the posterior end of the inferior turbinal. 

From one to three cuts are to be made the whole length of the lower 
turbinal, but only one cut at a sitting, the others to follow at intervals 
of three or four weeks, when their predecessors have healed. 



CHRONIC RHINITIS, SIMPLE AND INTUMESCENT. 



311 



The electrode having been carried to the back part of the tissue to be 
cauterized, and turned so that the i)latinum wire rests against the tissue, 
the circuit is closed, and as soon as the sound of burning is heard the 
electrode is drawn slowly forward, ,or, if the bone be not felt, moved 
slightly backward and forward until the instrument grazes the bone, and 
then drawn slowl}^ to the anterior end of the turbinated body, when it 
should be lifted from the soft tissue before the current is turned off, and 
then allowed to cool before it is withdrawn from the nostril. If the 
circuit be broken before the electrode is lifted from the tissue, the eschar 
is i^ulled off with it, and bleeding results. The wire should cut through 
the mucous membrane until it grates on the bone. It is necessary to 
keep the electrode constantly in motion, as if it be allowed to rest still 
for an instant it is sure to attach itself firmly to the tissues, from which it 
has to be torn with result- 

Fin. 1(T^. 



ing bleeding. The other 
side of the nose can be 
cauterized in from ten to 
fifteen days later, but both 
sides should never be cau- 
terized at one sitting. The 
cuts are usually made at 
the junction of the upi)er 
and lower thirds of the 
lateral surface of the lower 
turbinal with the middle 
third, but sometimes the 
lower border needs cau- 
terizing if it be pendulous. 
The very objectionable 
method of making frequent 
superficial cauterizations 
should be mentioned here ; 
it accomplishes nothing 
but distress and disappointment to the patient. The precision of motion 
and accuracj" of illumination of the deeper parts of the nasal i)assages 
required by the operation make its perfect performance a matter of con- 
siderable skill and steadiness of hand. If the Eustachian tube be very 
prominent it might be seared bj^ the electrode, if this be passed too far 
back. It is well, therefore, for the novice to practise with the cold elec- 
trode before turning on the current. Sometimes a single cauterization is 
sufficient permanently to reduce the swollen turbinal. but more often two 
or more are needed. Cauterization of the middle turbinal, if intumes- 
cent, does not ordinarily give good results. The swelling here is of a 
watery and dropsical order and less of a true intumescence, and is better 
removed with the cold snare, if possible. 




Ingals's cautery electrodes (two-fifths natural size). 1, 
guarded electrode used for superficial cauterization In hay 
fever; 2, knife-like electrode used in hypertrophic rhinitis; 3, 
4, and 5, electrodes for cauterizing the tonsils, follicles in the 
pharynx, and small spots in tiie nose ; 5. electrode for l)ase of 
tongue, or, when guarded by a piece of vulcanite fibre, for 
nasopharynx; 5, 6, and 7, tubular electrodes, into Avhich 
various-shaped points of platinum wire may be inserted for 
various purposes. 



312 DISEASES OF THE NOSE AND NASOPHARYNX. 

Complications. — It is not wise to cauterize a lower turbinal that lies 
close to the septum either because the turbinated bone is large or the 
sej)tum approaches close to it by deflection or exostosis. If cauterization 
be performed in such narrow passages, adhesions are very apt to occur 
between the turbinal and septum. Here the bony deformity should be 
removed by operation on the deformed septum or by removal of enough of 
the enlarged turbinated bone to make room. This can be done by sawing 
off its free border or b}^ passing a trephine through the turbinal to remove 
one or more small cylinders of bone beneath the mucous membrane, 
letting the turbinal collapse. 

In some cases adhesions will form at any rate, and it is well to let 
them alone until they have become organized and put on the stretch by 
the retracting turbinal, when they can easily be divided with the nasal 
scissors and kept open with a little lint. If severed while swelling still 
exists, the adhesions are likely to recur. Follicular tonsillitis and some- 
times otitis media have followed the operation, but they are rare compli- 
cations. Ei3istaxis may occur as late as the second week, but is seldom 
severe. Cauterizations should never be extensive or frequently repeated, 
as death from meningitis or sepsis has followed them. 

The after-effects of the operation are seldom more than a coryza with 
occlusion of the operated side from swelling. This usually lasts not 
more than from three to five days, and is followed by a water}^ or muco- 
purulent discharge, which in the second week becomes scanty, with a 
tendency to crust. Along the line of the cauter^^ wound false membrane 
usually makes its appearance and adheres till the second week. A solu- 
tion of five minims of oil of cloves to the ounce of oleum petrolatum 
album should be sprayed into the nares immediately before and after the 
operation. It should be followed by insufflation of a powder of two 
or three grains of iodol, and a light pledget of cotton kept in the nostril 
for a few days as a dust-filter. A four i)er cent, cocaine i30wder may 
be given to the patient, with directions to blow into the nostrils three 
or four times a day if the swelling and headache be severe. Oily ap- 
plications are indicated during the i^eriod when scabs are apt to form, a 
good formula being composed of thymol, one-third grain ; carbolic acid, 
one-half grain ; oil of cloves, three minims ; oleum petrolatum album, one 
ounce. If oily sprays irritate, a solution of boric acid, eight grains to 
the ounce, will be found beneficial. An excellent after-treatment is that 
recommended by Bresgen, consisting in painting the cauterized area with 
a saturated solution of methylene-blue by means of a small pledget of 
cotton. The application may be repeated once or twice after the opera- 
tion, but this is seldom needed. This method of after-treatment is usually 
so efficient that nothing further is required, except in some cases paint- 
ing the nostrils with vaseline to dissolve scabs or prevent their formation. 
The inflammatory reaction is decidedly less in those cases which have 
been treated with methylene-blue. The pharyngeal and laryngeal symp- 



CHRONIC RHINITIS, SIMPLE AND INTUMESCENT. 313 

toms usually improve when the nose is cleared, but may need independent 
treatment, while the aural complications always demand this. Though 
one may dismiss patients with all their sym^^toms relieved, other portions 
of the mucous membrane sometimes become intumescent, and after a few 
years further cauterizations may be needed. Other cases may be dismissed 
entirely cured after six or eight weeks of treatment. Though the cold 
snare is a very satisfactory instrument for removal of the swellings of 
hypertrophic rhinitis, it can seldom be employed in the intumescent 
form of the disease, as the wire loop will usually slip off instead of 
seizing the protuberant mucous membrane. If this be retracted by 
cocaine, it is quite impossible to use the wire loop. D. Braden Kyle 
makes linear incisions instead of cauterizations, and reports better results 
than from the galvano-cautery. 



CHAPTEE IX. 

HYPERTEOPHIC AND ATROPHIC RHINITIS, 
HYPERTROPHIC RHINITIS. 

In hypertrophic rhinitis the chronic congestion of the nasal mucous 
membrane has led to a true connective-tissue hyperplasia, localized chiefly 
on the inferior and middle turbinals and the septum. 

Microscopic Anatomy. — In hyi)ertrophic rhinitis the round-celled infil- 
tration so prominent in the simple chronic form has had time to recede, 
its place being taken by new connective tissue, which later becomes 
dense and firm. The epithelium shows the same metaplasias as in simple 
chronic rhinitis, but the number of layers of cells is even greater. The 
blood-vessels are dilated, and they and the glands are apt to be increased 



Fig. 109. 





Hypertrophy of the posterior ends of the in- 
ferior turbinated bodies. 



r^^- 



Polypoid swelling on the posterior free end of the 
middle turbinate. (Stoerk.) 



in number in the eaiiier stages, later lessening again, while in places 
the vessels become ectatic. 

Pathology. — In hypertrophic rhinitis the slight general thickening of 
the mucous membrane characteristic of simple chronic rhinitis has been 
replaced by hyperplastic swellings of a localized order. The structure 
most often showing these changes is the inferior turbinal. Its rich blood- 
supply and the venous stagnations in the erectile tissue to which this is 
subject favor an overgrowth of the connective -tissue and bony elements. 
The whole inferior turbinal is not always involved in hypertroi)hy, 
though this may occur. A frequent seat of these abnormal swellings is 
the posterior end of the lower turbinal, which may be so enlarged that it 
projects like a spherical tumor into the nasopharynx, and may meet its 
fellow behind the septum. These posterior swellings are apt to have a 
314 



HYPERTHOPHIC AXD ATKOPHIC RHIXITIS. 315 

nodular or raspberry-like surface resembling a x)apilloma ; nevertheless, 
there is in them no histological relation to true papilloma. In ex- 
treme cases the hj'pertrophic loortions of the inferior turbinals form 
ai)parently lobulated tumors, which have been called papillary fibro- 
mata, polypoid angiomata^ etc. They are not true tumors, however, 
but extreme hypertrophies. The color of the swollen portions of the 
inferior turbinals is usually dark bluish red : but in old cases, when the 
connective-tissue hyperplasia is great enough to diminish the vascularity, 
or when the epithelium is much thickened, the color is whitish. The 
anterior part of the lower turbinal is also occasionally liable to local- 
ized hypertrophy. This may be nodular and ridged in aj^pearance, or 
smooth as in intumescence. The hyperplasias of the middle turbinal are 
scarcely less frequent than those of the lower : they present a verj^ dif- 
ferent appearance, however, being usually confined to the lower border 

Fig. 111. 




Bilateral hypertrophic swelling of mucous membrane of septum. In the right choana hypertrophy of 
posterior end of middle turbinal. Complete obstruction of right naris. (Stoerk.) 

of the middle turbinal, and occupj^ it either as a single smooth, translu- 
cent, dropsical enlargement or as several polypoid protuberances having 
a broad base and hemisi^herical form, so that formations occur sug- 
gesting clusters of grapes, from which state it is but a step to the true 
nasal mucous polyx^us. The septal thickenings are usually found at the 
junction of the middle and upper third at the tuberculum septi, and just 
in front of the posterior free border of the vomer. The i)Osterior swell- 
ings are usually pale and smooth, and may be quite large and a con- 
siderable impediment to resi)iration. 

Si/mjyfoms. — The symptoms are essentially those of intumescent rhinitis, 
but differ in regard to the nasal obstruction which, though A'arying in 
degree, is constantly present, while in intumescent rhinitis it may be 
temporarily absent. The variations are due to the presence or absence of 
secretion and to the fact that some degree of intumescence capable of 



316 DISEASES OF THE ^'OSE AND NASOPHARYNX. 

changes in volume almost always accompanies turbinal and septal hy- 
pertrophy. In addition to the obstructed nose, the i^atient chiefly com- 
j)lains of the annoying secretions which collect in his nasopharynx, and 
there is often comiDlicating laryngitis. If hypertrophied, the middle 
turbinal shuts off the olfactory region from the air-current, so that there 
is frequent anosmia. Frontal or occipital headache and the various ner- 
vous symptoms described under intumescent rhinitis also occur, with 
asthenopia and the ocular complications mentioned in that section. 

The mucous membrane, especially over the inferior turbinated body, 
is thickened, and its surface is usually more or less uneven in appearance, 
sometimes presenting distinct nodules. The swelling varies greatly at 
times, being uniform over the whole turbinated body or limited to portions 
of it. When the posterior end of the inferior turbinated body is hyjDer- 
troi^hied it can be seen projecting into the nasopharynx as a rounded 
swelling, usually having an uneven surface resembling a large raspberry^ 

Fig. 112. 



Thickening of mucous membrane of septum. Nodular swelling of posterior ends of lower 

turbinals. (Stoerk.) 

forming a i)rominent and striking object of a dark bluish-red or whitish- 
gray color. The posterior end of the middle turbinal is sometimes also 
enlarged, and seen as a nodular tumor of polypoid appearance, of a pale, 
translucent, yellowish- pink color. The enlargements on the posterior 
portions of the septum appear as smooth, usually light gray prominences, 
commonly on each side of the vomer ; this may give to the rear end of 
the septum a spindle-shaped form. After inspecting the nasal surface a 
cocaine si3ray of four per cent, strength is to be applied to the mucous 
surface and the nasal foss?e again inspected. Whatever i)ortion of the 
swelling is due to mere intumescence will usually retract under the influ- 
ence of the cocaine, and the swelling that remains is in most cases due to 
true hypertrophy^ This, however, is not always the case, as under the 
stimulus of the cautery parts contract down to the bone which will not 
do so for cocaine. Cocaine is therefore not an absolute means of diag- 
nosis between intumescent and hypertrophic rhinitis. In some cases one 



HYPERTEOPHIC AXD ATROPHIC P.HIXITIS. 



317 



finds that not only tlie mucous surface but the turbinated bones them- 
selves have enlarged as a result of hypertrophic rhinitis. 

Hypertrophy of the middle turbinals is found less frequently than that 
of the inferior, but it is not a rare condition. The anterior portion is the 
favorite seat of enlargements, and the smooth, translucent, often nodular, 
masses, of pale-pinkish hue, can be seen to press against the septum, 
closing the olfactory fissure and causing anosmia and neuralgic pains in 
the forehead and eyes. It is especially the lower border of the middle 
turbinal that is found enlarged. 

Diagnosis. — The diseases to be distinguished from hyi:)ertrophic rhi- 
nitis are intumescent rhinitis, syphilis of the nose, and nasal mucous 

Fig. 113. 




Left nasal fossa. (Bresgen.) H, polypoid thickeniugof anterior end of middle turbinal {M) ; the 
latter and the lower turbinal ( V) present marked hj-pertrophy of the mucosa of the posterior ends : 
T, orifice of Eustachian tube ; P, polypus in the superior meatus. 



polyi)i. The readiness with which the probe will displace the swelling 
and press against the bone in intumescent rhinitis and the usual sub- 
sidence of the tumefaction under cocaine are the main points in diagnosis. 
In hypertrophic rhinitis the tissues give an impression of solidity when 
pressed upon, and their surface is irregular and uneven, while it is smooth 
in intumescent rhinitis. Diffuse gummatous infiltration of the nasal mu- 
cous membrane without ulceration may be hard to distinguish from hy- 
pertrophies of a non-syphilitic nature, and one must often await the 
results of specific treatment for purposes of diagnosis. Xasal mucous 
polypi hardly ever originate from the lower turbinal. As there is a histo- 



olQ DISEASES OF THE NOSE AND NASOPHARYNX. 

logical unity between the polypoid hypertrophies of the middle turbinal 
and true mucous polypi, and as the latter often result from these hyper- 
trophies, it is often hard to tell where the polypoid degeneration of 
hypertrophic rhinitis ends and the true polypus begins. The enlarged 
posterior end of the lower turbinal has some resemblance to a polypus, 
but it has a rougher surface, and is usually bluish-red or white, while 
the polypus can be seen resting on the soft palate as a glassy, oyster- 
like, smooth gray tumor, generally large enough to hide the whole of one 
choana from view. 

Frognosis, — If left to itself, hypertrophic rhinitis seldom shows any 
tendency to spontaneous recovery, excepting after months or years. This 
may occur in favorable cases, the hyperplasia receding until the affected 
parts resume their normal appearance or atrophy occur. In many cases 
the hypertrophy gradually increases, and when its maximum is reached 
remains unchanged indefinitely. It is certain that in a considerable 
number of cases shrinkage of the affected mucous membrane and tur- 
binated bones sets in, and continues until atrophic rhinitis with ozsena 
develops. In one case this process was seen to run its course in eighteen 
months. Moritz Schmidt has seen atrophy and hypertrophy coexist on 
the same turbinal, and thinks it logical to su^^pose that, as in other 
mucous membranes, the hypertrophic process has advanced in some por- 
tions to atrophy, while in others it is still in the hypertrophic stage. 

Sinus disease, fortunately, only in rare cases results from hypertrophic 
rhinitis, and when it does it may lead to meningitis or sepsis. When 
treatment is patiently pursued in hypertrophic rhinitis by both patient 
and physician the prognosis becomes favorable both as to the disease and 
its usual complications. The discharge disappears, the headaches cease, 
and the voice becomes normal, but the sense of smell does not always 
return and the secondary changes in the middle ear may be irremediable. 
The so-called reflex neuroses will often disappoint the surgeon by per- 
sisting after the rhinitis has been removed. 

Treatment. — The treatment of hypertrophic rhinitis is chiefly sur- 
gical, with general and local treatment as adjuvants. In reduction by 
chemical measures, monochloracetic, trichloracetic, and chromic acids 
are the ones most to be recommended. Of these chromic acid is the 
most efficient, but the other two are less liable to cause adhesions. 
Eeduction of hypertrophic swellings by chemical means, however, is not 
to be recommended, as other measures are so much more rapid and 
efficient. Of these the cold snare is to be preferred when it can be 
emi3loyed, as it removes the hypertrophic masses bodily and the re- 
action after its use is very slight, while relapses of the hypertrophic 
condition do not occur with the same frequency as after the galvano- 
cautery. After taking away as much redundancy of tissue as one can 
with the snare, it is often needful to complete the treatment with the 
galvano-cautery. 



HYPERTROPHIC AND ATROPHIC RHINITIS. 319 

In hypertrophic rhinitis the swellings are ordinarily not purely 
hyperplastic, but are partly due to dilatation of the vessels of the mucous 
membrane. Cocaine contracts these and so diminishes the volume of 
the tissues that the snare may glide from them ; therefore it is well to 
apply the latter gently, but with enough constriction to get a firm hold 
before applying the cocaine. Many patients will submit to the opera- 
tion without cocaine if the snare be tightened slowly and intermittently, 
the constriction ceasing as soon as the patient winces from pain and be- 
ginning again when the pressure has benumbed the tissues. Another 
advantage of importance is that slow tightening of the snare makes the 
operation almost bloodless, while raj)id resection of the tissues causes 
free hemorrhage, l^evertheless, after removal of portions of the lower 
turbinal with the snare it is well to pack the nasal fossa with lint pow- 
dered with bismuth or iodol and boric acid, as, if it be left unpacked, 
bleeding may commence some time after the operation when the patient 
is out of the surgeon's reach. The packing may be removed after the 
second day ; its method of application will be described under operations 
for deformities of the septum. 

When the snare cannot be made to take hold of the tissues of the 
anterior parts of the turbinals, a needle 

may be thrust through the mucous F^g. lU. 

membrane and the snare applied over 
this, but ordinarily such cases are better 
treated with the galvano- cautery. Hy- 
pertrophies of the anterior end of the 
middle turbinal are favorable objects 
to catch in the wire loop, and usually 
there is but little difficulty in removing 
them to the bone with this implement. 

rj.-, ^ , , , . T J* i_i • T Ti Ingals's nasal scissors (one-third natural 

Those of the posterior end of the middle size). 

turbinal are the most difficult of access 

of all the hypertrophies. When the wire loop cannot be applied, some 
variety of cutting forceps may be used. Yery often there is not room to 
seize much with the forceps, and in these cases a small ring-knife on a 
slender stem or the instrument called the spokeshave is more effective 
than the forceps. The spokeshave blade best suited to the work is pear- 
shaped. These ring-knife blades scrape off the polypoid hypertrophies 
piecemeal. 

The hypertrophied posterior end of the lower turbinal is, as a rule, 
not difficult to engage in the wire loo]3. A loop of suitable size is to be 
bent at right angles to the snare-tube, and withdrawn a little within this 
to facilitate introduction within the nose. The loop should be passed 
along the lower meatus, and as soon as it has entered the nasopharynx it 
should be pushed out of the tube again to the proper distance, and so 
held that it will spring outward towards the lateral pharyngeal wall. It 




320 



DISEASES OF THE NOSE AND NASOPHARYNX. 



should then be pressed upward and outward and drawn forward until it 
can be felt to lightly engage the swollen end of the turbinal. Then the 
end of the tube must be firmly pressed into the tissues and the snare 
tightened. Sometimes passing the finger into the nasopharynx is of use 
in applying the loop. When the use of the snare is impossible, it is best 
to cauterize the tissues of the lower turbinal with the galvano- cautery, 
but the results are not so certain as in intumescent rhinitis. The most 
efficient method of cauterization is that described under intumescent rhi- 
nitis, where it is shown that two or three linear incisions are usually 

Fig. 115. 




Nasal trephines (actual size). Modification of Curtis. 

sufficient to reduce the hypertrophy. The lower turbinal must be 
cauterized along its whole length; therefore it is well to measure the 
depth of the nasal fossa as far as the posterior end of the lower turbinated 
body, in order to be sure to include this in the cauterization. This 
measurement can be performed in the manner described in the article 
on intumescent rhinitis, or perhaps the end of the electrode can be seen 
by posterior rhinoscopy. If the electrode be passed too far back it may 
burn the Eustachian orifice, an accident apt to be followed by pain and 
possibly otitis media. 

Enlargement of the turbinated bones themselves requires their re- 
section. Ordinarily it is the lower turbinal that is involved, and the 
free edge or more of it can be taken off with the saw or strong nasal 

Fig. 116. 




Nasal burrs (actual size). 

scissors. A better method is that of drilling out a core from the bone 
with the dental burr or trephine. These instruments, attached to the 
electric motor dental engine, are run beneath the mucous membrane, 
enough of the bone being removed to allow the soft tissue to contract 
until sufficient space be obtained. When it is not possible to remove 
the redundant tissue from the middle turbinal, cauterizations may be 
indicated. A small loop-like or jjointed electrode may be used with 
advantage, and is to be thrust into the lower edge of the turbinal in 
three or four places. D. B. Kyle, in operating on the lower turbinal. 



HYPERTROPHIC AND ATROPHIC RHIXITIS. 321 

makes two oblique linear cuts with a special knife, so as to remove a 
long prism-shaped piece, the apex of which is attached to the bone, 
while the base corresponds to the free surface of the turbinated body. 
This is finally separated from the bone by the snare or saw- scissors. 
Even if the hemorrhage in this operation be not of serious consequence 
to the patient, it will at least so obscure the field of vision that the 
accurate performance of the second incision will be doubtful. 

Electrolysis effectually' reduces the redundant tissue, and is followed 
by so. little local reaction that the absence of consecutive inflammation 
is one of its chief advantages. It is performed by means of the bij^olar 
electrode, consisting of two needles made of steel, platinum, or iridio- 
platinum. The positive needle, if of steel, is attacked and roughened 
by the current, and platinum is so soft that it bends too readily, so that 
iridio-platinum is to be preferred. The current to be used should measure 
from twenty to forty milliamperes, twenty milliamperes being the usual 
limit of endurance, as, in si3ite of cocaine, the process is painful. A 
rheostat, preferably of grai^hite, is a necessity, as all sudden changes in 
the current must be avoided because they are painfully startling. The 
current should start at nothing, be slowly increased to the amperage 
mentioned, and reduced as gradually, a sitting of six minutes being 
sufficient. The chief objection to electrolysis is the slowness with which 
results are gained ; its advantage is the absence of inflammatory reac- 
tion and consecutive adhesions. If adhesions follow the other methods 
of oi:>eration, electrolysis is the best means for their removal, as the de- 
struction caused by its use is not followed by the exuberant granula- 
tions often seen after operations with the saw-scissors or caustics, in 
which granulations si:)eedily leuew the adhesion previously destroyed. 
A battery of at least twenty-four cells is needed to furnish a current 
of sufficient voltage to overcome the resistance of the tissues and give 
the required current of twenty milliamperes, the number of volts re- 
quired being from forty to eighty. Graphite rheostats can now be ob- 
tained which will reduce a direct galvanic current of one hundred and 
ten volts — the current usual for incandescent lam^^s — to nothing, if de- 
sired. It is necessary to have a sixteen-candle-power lamp in series 
with the rheostat to keep it from getting hot. A rheostat of this kind 
obviates the need of a battery, but the alternating current cannot be 
used for electrolysis. The needles are to be thrust into the tissues for 
their whole length, and before their introduction the strength of current 
is to be tested by connecting them bj^ a pledget of wet cotton, while the 
amount of current is measured with the milliamperemeter, and should 
be twenty milliamperes. The action of the galvanic current causes a 
white foam to appear about the needles, the slough created being more 
noticeable after a few days. After its separation the tissues look as if a 
piece had been cleanly bitten out of them. The hypertrophies on the 
septum can be removed with cuttiug forceps or reduced by the galvano- 

21 



322 DISEASES OF THE NOSE AND NASOPHARYNX. 

cautery, but electrolysis can also be used here witli success. The sur- 
geon can locate the position of the needles at the back of the septum by 
posterior rhinoscopy. 

The galvano-cautery snare is used by some oi^erators for removal 
of hypertrophies of the turbinals. The advantage it offers is lack of 
bleeding, an advantage more than offset by the greater difficulty of 
manipulation of the snare by reason of the heavy attached cords. 
Another objection to the hot snare is the inflammatory reaction which 
follows its use, while there is but little after operations with the cold 
snare. 

Metallic, gutta-percha, or soft-rubber tubes, sponge and laminaria 
tents have all been recommended for the treatment of hypertrophic rhi- 
nitis by pressure, but may be regarded as practically obsolete. 

Care is to be taken not to make the nasal fossae too roomy by opera- 
tive measures, lest one produce conditions similar to those of atrophic 
rhinitis, with nasal ]Dassages so large that the air is not moistened 
enough by the diminished mucous surface, and the secretions dry and 
accumulate. On the other hand, timid treatment will produce but par- 
tial and temporary relief ; hence the patient who has been given an 
atomizer wherewith to blow away his mucous hypertrophies is, unfor- 
tunately, common. Fear of hemorrhage is the chief deterrent from 
operative measures, but this can be controlled by packing the nares 
with strips of lint saturated with bismuth subnitrate or iodol and boric 
acid powder. If properly done, this will absolutely control bleeding, 
while, owing to the i)owder, the plug will remain odorless and aseptic 
for a week, though, as a rule, it need not be retained more than two 
days. Therefore, fear of bleeding need not deter one from the use of 
the snare, scissors, or other cutting instruments. The method of packing 
the nasal cavity is' described under epistaxis. 

ATROPHIC RHINITIS. 

In atrophic rhinitis the mucous membrane, as well as the bony frame- 
work of the nasal cavity, atrophies. These changes are most marked on 
the turbinals, which shrink away, leaving the nasal fossae abnormally 
roomy, while at the same time an extensive epithelial metaplasia from 
ciliated to pavement ei)ithelium makes i:)0ssible the adhesion to the mu- 
cous surface of dried secretions in the form of crusts. In the majority 
of cases these emit an offensive odor, producing a condition called ozsena. 
The nasal bones may be normal, but in many cases are shortened in all 
directions, so that the nasal bridge sinks in, making the flat, pug, or 
saddle nose often characteristic of the disease. The mucous surface may 
remain comparatively intact, while the bone shows the greater atrophy. 
The septum also diminishes in size, growing shorter from before back- 
ward, as the investigations of Hopmann have shown. 

If the crusts be lifted off, their under surfaces are found moist or cov- 



HYPERTROPHIC AND ATROPHIC RHINITIS. 



323 



ered with fluid piis. The offensive odor of ozsena clings to these crusts, 
and usually disappears with their removal. The crusts may be discrete or 



Fig. 11 




Right nasal fossa. Atrophy of mucous membrane and turbinated bones. (Zuckerkandl.) 3/, middle 
turbinal ; U, lower turbinal ; T. Eustachian tube. 

line the entire nasal cavity like a cast. The mucous membrane is pale, 
neither eroded nor ulcerated, and in advanced cases is firmly attached to 
the bony surface like a thin serous membrane. Extreme atroi^hy of the 
turbinals makes x)ossible direct inspection of the nasopharynx and Eu- 



FiG. 118. 




Metaplasia of cylindrical epithelium of nasal mucosa to pavement epithelium. (Stoerk.) a, epi- 
dermis-like change of epithelium ; b, preserved cylindrical epithelium in a state of secretion ; c, mucous 
gland. 

stachian orifice, the infundibulum with the openings of the accessory 
sinuses, and the orifice of the sphenoidal sinus. 



324 



DISEASES OF THE NOSE AND NASOPHARYNX. 



Microscopically, there are found in the less advanced cases areas of 
pavement epithelium where normally the ciliated kind should be found. 
Early in the disease the submucous tissues present the round-celled in- 
filtration usual to chronic inflammatory processes ; later these organize 
into cicatricial tissue. The mucous glands become obliterated, suffer 
ampullar enlargement in places, diminish in number, and the muscular 
elements of the erectile tissue atrophy. The specialized epithelium of 
the olfactory region also suffers metaplasia, so that in most cases of 
atrophic rhinitis the sense of smell is lost. Frankel found that the 



Fig. 119. 























k^. 










Section of entire thickness of mucous membrane in atrophic rhinitis. (Stoerk.) a, pavement 
epithelium ; b, b, connective tissue moderately rich in cells ; c, c, glands largely degenerated ; d, blood- 
vessel with excessively enlarged Avail. 



fresh secretion obtained just after cleansing contained but few micro- 
organisms and had no fetor, but that removed after six hours was putrid 
and loaded with bacteria. Abel, Paulsen, and other observers found 
among these a bacillus constantly present on the mucous surface, which 
is called the bacillus capsulatus mucosus, and to which they attributed 
the disease. 

Etiology. — The question of the etiology of atrophic rhinitis is at present 
the subject of controversy. The usual opinion is that atrophic rhinitis 



HYPERTROPHIC AND ATROPHIC EHIXITIS, 



325 



Fig. 120. 



is the last stage of the hypertrophic variety. This is the view of the 
majority of observers. In reviewing all the opinions of the etiology of 
ozsena, it is shown that this disease can originate in several ways, and 
that it is probably the final stage of more than one morbid process. In 
some cases the affection is the result of hypertrophic rhinitis, while sinus 
disease will certainly account for far more cases of atrophic rhinitis 
than has been supposed, and should be looked for with more diligence 
than heretofore in every case of ozsena. 

Symptoms. — The general health of the patient may be unimpaired ; 
indeed, it is remarkable how little it suffers from the disease. The head- 
aches and irritative symptoms of the other forms of rhinitis hardly dis- 
turb the sufferer from ozsena, the ^.trophic mucous surface not being sen- 
sitive. When sinus disease exists as a complication or cause, distress- 
ing neuralgias and headaches often accompany this condition. What 
causes the greatest distress to the patient is the fact that he is an object 
of disgust to others on account of the 
stench emitted from his nostrils. The 
foul smell of ozsena may be so great 
as to fill a room ; in other cases one 
must approach the patient closely to 
notice it. He ordinarily has no i)er- 
ception of the odor, as his olfactory 
sense is blunted or destroyed by the 
atrophy of the olfactory nerve-ends. 
There are cases of atrophic rhinitis 
unaccompanied by any odor. Breath- 
ing through the nose is generally un- 
obstructed unless pus and crusts block 
up the nares. In most cases there is 
no discharge from the nostrils, the se- 
cretions being blown from the nose 
or hawked back into the pharynx every few days, in solid form, in the 
shape of offensive crusts. If large and hard, these may come awaj^ with 
difficulty, causing nose-bleed at times, or, if delivered by the nasophar- 
ynx, they may create retching and vomiting. Their presence in the nose, 
if of sufficient size and consistency to cause pressure, will result in pain 
in the nose and forehead till they are removed. The secretion does not 
always consist of dry scabs, but may be semifluid adherent pus or soft 
purulent coagula. 

Insxyection. — The secretions generally do not cover the mucous surface 
entirely, but lie on it in areas of varying size and consistency, from large, 
hard, yellow or gray scabs which cover an entire turbinal or side of the 
septum to pasty patches of sticky pus. When they are removed, all 
degrees of atrophy of the turbinals and mucous membrane are found, at 
times coexisting with regions of hypertrophy. Atrophic rhinitis may 




Bacillus of ozsena. (M. Schmidt.) 



326 DISEASES OF THE NOSE AND NASOPHARYNX. 

even be confined to one side of the nose, and here the possibility of sinus 
disease as a cause is very great. In well-marked cases of atrophic rhinitis 
the turbinals have shrunken to mere ridges, and the nasopharynx, 
Eustachian orifices, and motions of the soft palate are i3lainly visible. 
Fortunately, the outlets of the accessory sinuses also become abnormally 
exposed by the disease process, so that in some cases the openings of the 
sphenoidal sinus, ethmoidal cells, and the orifice of the frontal sinus in 
the infundibulum become visible and in all are more easily reached with 
a probe than in health. This is of value in considering the possibil- 
ity of sinus disease as a cause of atrophic rhinitis. The atrophy of the 
mucous membrane does not always keep pace with that of the bones. 
EsxDCcially in the upper part of the nose, portions of the mucosa may hang 
down in swollen, congested, reddened folds, irritated by constant contact 
with pus and bleeding readily when touched, while the atrophied tur- 
binated bone no longer gives support, so that these pendulous masses of 
mucous membrane are freely movable. The disease process rarely stops 
in the nares, and involvement of the nasopharynx and, unfortunately, of 
the middle ear is very common. The latter complication creates, as a 
rule, intractable middle-ear sclerosis, while otitis media suppurativa is 
rare. In some cases the disease process extends to the larynx and far 
down the trachea, both being lined with dry patches of secretion, while 
the swollen and reddened laryngeal mucous membrane is covered with 
adherent pus, the voice failing greatly in these cases. The vault and 
often the lateral walls of the nasopharynx are frequently the seat of ac- 
cumulations of dry scabs or of semifluid i)us. 

Diagnosis. — Syphilis of the nose is the condition most likely to be 
mistaken for ozsena, esjDecially when the former has led to wide-spread 
destruction of the turbinals with subsequent cicatrization. Here, as in 
ozsena, may occur cell- metaplasia and crusting, but the defects in the 
bony septum almost always left by the disease enable one to make a diag- 
nosis, even if there be no longer any dead bone present. In cases of 
nasal syphilis in which the disease is still active, necrotic bone and ulcer- 
ation differentiate from atrophic rhinitis. 

Simple recent suppuration of the antrum or frontal sinuses presents 
a picture quite different from that of atrophic rhinitis. The appear- 
ance of pus flowing in the middle meatus, usually on one side only, its 
obstinate reappearance when wiped away, and the freedom of the rest 
of the nasal cavity from disease serve, with the other sym^^toms of sup- 
puration of the antrum or frontal sinus, to differentiate this state from 
ozsena. The pus also, though of a foul odor, does not produce the stink- 
ing breath of atrophic rhinitis, and its smell is generally noticed by the 
patient himself, while in atrophic rhinitis the sense of smell is usually 
lost. 

Chronic suppuration of the ethmoidal cells or sphenoidal sinuses, on 
the other hand, presents a picture so like that of ozsena that extremists 



C H A P T E E X. 

NASAL Tr:\IORS. 

XASAL MUCOUS POLYPI. 
Synonyme. — Xasal myxomata. 

Xasal mucous polypi are not myxomata, but outgrowths from the 
connective tissue of the nasal mucous surface, and hence are to be con- 
sidered fibromata. They occur often in great numbers in the nasal 
fossse, and are apt to block these comj)Ietely. They are either pe- 
dunculated or sessile, and in most cases give rise to a free mucous 
discharge. 

Etiology. — It is probable that nasal mucous x>olypi are the result of 
chronic rhinitis, and rei^resent a hj'perx^lasia in a state of oedema. All 
observers do not, however, agree with this view, notaWy Barbier, of 
Lyons. Paul Heymann is of the opinion that, as tlie result of irritations, 
the mucous surface loses its normal smoothness, develops papillae, and 
that some of these undergo oedematous hyi^erj^lasia, gradually becoming 
nasal mucous polyx^i, whose growth is favored by gravity and oedema dne 
to obstructed return circulation through their stems. 

Polypi have been found in i)eople of all ages, and may even be con- 
genital 5 they are, however, rare in childhood and old age. They are 
commonest between the ages of twenty-five and fifty. An hereditary 
j)redisposition doubtless exists in some cases. 

Fathology. — The typical mucous polyi^us is attached to its base by a 
slender neck or peduncle, and is of varying shape, though usually pyri- 
form or globular, and the average specimen varies in size from that of a 
pea to that of a walnut. Its consistency and color resemble those of 
an oyster, and it possesses a jelly-like translucence and a smooth and 
glistening surface. Often fine blood-vessels are seen entering the pedun- 
cle and spreading in delicate branches over the surface of the growth, 
but the variations from this tx]}Q are many. The pol3'x:)us may be firm 
and opaque as connective tissue predominates in its structure, or it 
may be quite red if blood-vessels form a large part of its substance. 
When the epithelium is much exj)osed to the air or to irritation, as 
when the growths are located in the nasal vestibule or nasopharynx, it 
becomes like epidermis and covers the surface with a white, opaque 
coating. In size polypi vary from microscoi3ic dimensions to enormous 
growths which force aside the nasal bones and bony framework of the 
inner nose and appear externally or extend down to the larynx. Such 
growths may be four or five inches in length and correspondingh' bulky. 

331 



332 



DISEASES OF THE NOSE AND NASOPHARYNX. 



Polypi may have several lobes, and their attachment may be broad, so 
that they form sessile tumors. The sha^De of the larger ones is much 
influenced by the nasal passages in which they grow, so that they may 
be long and flattened or branched to fit into the meatuses or into one 
another. Those found in the nasopharynx assume a globular or pyri- 
form shape. Polypi may be very numerous, but generally not more 
than from six to ten are found in one nasal fossa. 

The source of origin is oftenest the lower border of the middle tur- 
binal and middle meatus, but they may grow from any part of the 
mucous surface, even the septum, the lower turbinal, and the nasal floor, 
though polypi in these last-named locations are very rare and usually 
single. 

The ethmoid region forms the territory on which mucous polypi 

Fig. 122. ^ 




Right nasal fossa. (Bresgen.) Two large polypi (P P) with more than one attachment ; T, Eustachian 

tube. 



flourish, so that the middle turbinal, middle meatus, upper turbinal, and 
upper meatus are the chief places of origin of these growths. They are 
also found attached to the edges of the hiatus semilunaris, or growing 
from the openings of the accessory sinuses, or originating even from 
within the antrum of Highmore and the ethmoid cells. 

Nasal mucous polypi are connective-tissue growths. In the typical 
soft polypus this forms a delicate reticulum of fibres resembling embry- 
onal connective tissue, the reticulum consisting of a coarser net- work 
of fibres enclosing a finer one. The outer surface of the nasal mucous 
polypus is covered with ciliated epithelium and a basement membrane 
like the rest of the mucous lining or the nasal fossae. In places the 



NASAL TUMOES. 



333 



epithelium may change to the pavement variet3\ Nerve-fibres have 
been demonstrated in these growths. 

Symptoms. — Nasal mucous polypi may cause no symptoms so long as 
they are small. When larger they give rise to mechanical irritation and 
corresponding discharge of a serous or purulent nature from the nasal 
mucous membrane. The purulent secretion stimulates the mucous sur- 
face to the production of more polj^pi, and, in fact, the discharge from 
sinus disease or other nasal supi)uration may originate the growths. As 
these get larger they are often felt by the patient moving back and 
forth as a foreign body, and soon begin to occlude the nares more or less 
comi^letely. 

The olfactory region may be early shut off from the air-current, so 
that anosmia may exist long before nasal occlusion. In some roomy 
nasal fossae this latter symptom may remain moderate. 

Fig. 123. 







Section of polypus. (Heyraann.) The areolar tissue is especially well shown. The epithelium is cili- 
ated to the left ; to the right it shows change to pavement epithelium. Enlargement, 1 X 20. 

Pressure on the Eustachian orifice or the aspiration of air from the 
middle ear, due to complete nasal occlusion, stops the ventilation of the 
middle ear, and deafness is a frequent symj^tom. If originating from 
the lower turbinal, a growth may close the tear-duct. A sense of i)ressure 
and fulness in the nose is often felt by the patient, and neuralgic pains 
radiating into the various branches of the first and second divisions 
of the fifth cranial nerves are common symptoms. Eeflex asthma is 
frequently caused by polypi, and nightmare, headache, giddiness, epi- 
lepsy, congestion of the fauces, hay fever, and other reflex disturbances 
sometimes result from the presence of these growths, but these conditions 
usually have no connection with nasal mucous polypi. Vascular polypi 
may give rise to obstinate and severe epistaxis. Damp weather causes 
nasal mucous polypi to swell because of their hygroscopic qualities, so 



334 



DISEASES OF THE NOSE AND NASOPHAEYNX. 



that patients feel best when the air is dry. Very large polypi may 
distend the external nose and cause the disfigurement called frog-face, 
while the end of the growth may protrude from the nostril as a red, 
angry-looking tumor. 

Inspection by anterior rhinoscopy is aided by the application of a 
four per cent, solution of cocaine with a swab to the usually swollen 
nasal mucous surface, which will shrink after the application, while the 
polypi will not be affected by it, and hence will come clearly into view. 
They present themselves as translucent, glistening, grayish bodies of an 
appearance so characteristic that they form a very easy object for diag- 
nosis by inspection if far enough forward in the nasal passages, but* if 
they be hidden behind some obstacle, as a septal deflection or spur, 
so that only a small part is visible at one time, they may easily be mis- 
taken for a collection of mucus. Those growths which are placed far 

Fig. 124. 




Mucosa of middle turbinal of an eight-year-old girl, showing papillary change preliminary to the 
formation of mucous polypi. (Heymann.) 



back in the nares may be hidden from sight when anterior rhinoscopy 
is used, but may be visible if posterior rhinoscopj^ be employed, and 
can be seen lying in the meatuses or between the turbinals and the sep- 
tum or resting on the soft palate, and, if large enough, obscuring the 
view of the nasopharynx. Unless the growths be packed in too tightly, 
they can often be seen to move back and forth in the air-current, if 
the patient breathe forcibly. Sessile polypi with broad attachments 
are not readily distinguished from their surroundings, and the probe 
is needed to determine their limited mobility, while their hyaline, lob- 
ulated appearance and contrast with neighboring parts of normal mu- 
cous membrane aid in their recognition. In inspecting the nares for 
polypi the probe is of great service in determining mobility and con- 
sistency. 

Diag7iosis. — Polypi are to be diagnosed from malignant tumors by the 



XASAL TUMORS. 335 

irregular surface of the latter, and by the fact that this surface is apt 
to be sloughing or ulcerated, gray, and discolored. Polypi are distin- 
guished by their firmness, broad attachment, great tendency to bleed, 
ra]3id growth in most instances, prompt recurrence after removal, and 
the pain which is apt to accomi)any them. Osteomata and chondro- 
mata are hard and immovable, as are also osseous cysts of the mid- 
dle turbinal. Foreign bodies are surrounded by injected elevations of 
mucous membrane and give rise to discharge, which is usually offensive 
and unilateral. Chronic abscess of the septum has a broad base and 
appears on both sides. It and septal deflections and exostoses can be 
diagnosed from nasal mucous polypi by the fact that a probe can be 
passed between the polypus and the septum, while it cannot enter be- 
tween the sex)tuni and the other protuberances mentioned. Tubercular 
and syphilitic tumors on the sei^tum are generally distinguished by the 
accompanying ulceration or perforation. Gummata which have not ul- 
cerated have a broad, smooth base. Hypertroi)hy and swelling of the 
turbinals may mislead those unused to rhinoscopy. Cases have often 
been observed in which inexperienced or careless operators trying to 
snare a polypus have seized one of the turbinals instead. Eetraction 
under cocaine, and the fact that a i)robe cannot be passed between the 
large turbinal and the outer nasal wall, ought to undeceive even the 
novice. Those used to rhinoscopic appearances will hardly mistake 
polypi for any other condition. 

Prognosis. — Polyi^i remain benign growths, and a change to malignancy 
is not to be exi^ected. The effect on the patient's health involves the 
usual deleterious consequences of mouth-breathing. Earely are nasal 
mucous polyi)i permitted to attain a size that will cause rarefaction 
and displacement of the bones which frame the nasal cavity. Sponta- 
neous disappearance of the growths does not occur. The most important 
thing to be considered in prognosis is recurrence of the tumors after 
operation. 

Thorough removal of x^oh^ii at their origin is desirable, but not 
always possible when they si)ring from hidden i^laces which are unreach- 
able with instruments ; but even if a considerable portion of the growth 
be left behind, this usually shrinks away. 

Eeapi)earance of polypi in the nose is due to the growth of small ones 
which have not been removed, and which, relieved from pressure, in- 
crease rax)idly in size, or it may be due to the formation of polyi)i from 
remaining papillary prominences on the irritated mucous surface from 
which the growths have S]3routed. Eemoval of this irritation and of 
the bed from which the polyx^i spring will stop the occurrence of the 
growths. For this reason the older surgeons, in evulsing polyjDi with the 
polypus forceps, tried to seize and tear away part of the turbinals. 

Treatment. — Eemoval of nasal mucous polyi^i by means of caustics 
such as chromic acid is uncertain, tedious, and, considering the superi- 



336 DISEASES OF THE NOSE AND NASOPHAEYNX. 

ority of other methods, hardly worthy of mention. Some surgeons still 
clear the nose of the growths with the polypus forceps. This barbarous 
method is an historical survival, and only to be accounted for by the fact 
that many do not master the simple technique of rhinoscopy. The oper- 
ation is performed without the aid of a mirror, the forceps being guided 
by the hand without the help of the sense of sight, so that great damage 
has been done to the nasal interior, whole turbinals having been torn 
away and the septum fractured, while the slippery polyi)i have to a great 
extent eluded the grasp of the blades, or have been removed only in part. 
The pain and bleeding caused by the method are extreme, and its conse- 
quences may be destruction of a large part of the physiologically impor- 
tant turbinals. A considerable number of cases of meningitis, as stated 
by Heymann, have followed the operation, even when performed by 
skilful surgeons. 

The operation most in favor at present is the removal of the polypi 
with the cold snare. The gal vano- caustic wire has its advocates, the 



Fig. 125. 




!^N^SR»!W!^;gy;!;s5»^y^^ J 



Mcintosh cautery snare. 

searing of the base by the caustic heat having a supposed influence in 
preventing recurrences. In some cases its use has led to erysipelas. 
In addition, the apparatus required is complicated, while the heavy 
cords and handle of the galvano- cautery impede the surgeon's move- 
ments. 

As a preliminary to the operation with the cold snare or any other 
method, the parts are to be anaesthetized with a four per cent, solution 
of cocaine. This is to be applied as follows. A long, fine nozzle of silver 
is screwed to a hypodermic syringe. This is drawn full of the cocaine 
solution, that is forced through the syringe, drop by drop, after the end 
of the fine tube has been passed up to the source of origin of the polypi. 
This confines the anaesthesia largely to the parts on which the surgeon 
intends to operate, and reduces the amount of cocaine used to a minimum. 
The snare should be armed with No. 5 steel piano-wire. This must be 
fastened around the pegs on the side of the snare in such a way that 



NASAL TUMORS. 337 

tlie wire crosses itself at each turn in a figure-of-8. This will prevent 
its becoming loose when under a strain. The tendency is to make the 
size of the looi) too large, so that it becomes hard to manipulate in the 
nasal fossce. The length of the loop must of course vary according to the 
size of the growth to be removed, but a good average is one inch. In 
addition to the snare, a pair of very small pliers is needed to straighten 
the looji after it has been used. The snare most to be recommended is 
a modification of an aural snare devised by Clarence J. Blake, called 
Ingals's snare. The loop should be introduced vertically along the sep- 
tum, and between this and the polypus. As soon as it seems to be di- 
rectly under the base of the growth it must be changed from a iDOsition 
peri^endicular to the floor of the nose to one on the same i^lane ; in other 
words, it must be passed in on its side and then turned so that it looks 
upward. In this position it must be so moved about with the aid of a 
slight backward and forward motion that it will slip uj) on the polypus. 
The snare must be moved upward on the i)olypus until it reaches as near 
to the origin of the growth as i^ossible. As soon as the wire seems to be 
advanced as far up on the growth as it can go. it should be tightened by 

Fig. 120. 



Hypodermic syringe (half natural size). Long silver nozzle. 

pulling on the sliding carriage of the snare. It is possible to tell wliether 
the growth has been seized at its origin by moving the tightened loo}) 
back and fortli. If the polypus has been caught at its base, the snare will 
seem fixed to a firm object ; but if the surgeon has merely succeeded in 
seizing the polyp about its middle, it will seem as if the snare were fas- 
tened to a loose body. The looj) must be tightened to a sufficient extent 
to take a firm hold on the growth, which must then be torn away. 
This not only insm^es tearing away the tumor itself, with its source of 
origin, but generally removes a number of small polypi which spring 
from the same base, and operators often succeed in evulsing in this 
manner a whole bunch of polypi as large as that originally seized. This 
method is preferable to the one of cutting through each polypus separately 
by means of the milled nut snare. 

Sometimes the bunch of growths will not follow the snare after it has 
been cut off, but will lie in the nasal passages and have to be taken 
away with forceps or blown out by the patient. When one polypus 
or bunch of polypi has been removed, another one comes into view 
farther back in the nose : after this has been taken out, still another is 
seen, until at last the space is found clear of the growths back to the naso- 

22 



338 DISEASES OF THE NOSE AND NASOPHARYNX. 

pharynx. Tumors which are attached near the posterior nares, or those 
lying behind septal spurs or deflections, are often exceedingly difficult 
to engage in the snare. To accomplish this the spur or deflection may 
have to be removed as a preliminary to the snaring of the polypus. 
Forcible blowing of the nose will often bring polypi which are seated far 
back in the nasal fossa into a situation where they can more readily be 
reached. When the growths lie on the soft palate in the nasopharynx, 
they can often be caught by passing the wire loop through the nostril, its 
adjustment being aided, if necessary, by the finger introduced into the 
nasopharynx. If the polypus cannot be induced to enter the loop in this 
way, the wire may be passed by means of a curved tube into the naso- 
pharynx from behind the soft palate. This latter method is very diffi- 
cult and tedious, however, so that it is preferable to pass a pair of nasal 
forcei^s through the nares to seize the polypus and drag it into the nasal 
fossa, where it can be encircled with the wire of the snare. If the 
growth be too large for this, it can be torn away from behind by means of 
the Lowenberg forceps. Very small polypi which are too small to catch 
with the snare are best removed with nasal forceps with cutting blades. 
For this Ingals's nasal bone-forceps is well adapted, or the little growths 
can be destroyed by the gal vano- cautery. The latter is well adapted for 

Fig. 127. 

— __-— -^_ SHARPIV.ISMITH ^ ^ 



Cotton applicator (two-fifths natural size). Made of copper. 

reaching areas of polypi in difficult situations, as, for instance, the pos- 
terior ends of the middle turbinals. 

It is often not possible to clear a nasal fossa of polypi at one sitting, 
as the blood obscures the view and makes the attempts to snare the 
growths tedious and imperfect, so that by postponing their removal until 
another time the surgeon can oj^erate with more speed and perfection. 
The bleeding during the operation is seldom great ; but very little blood — 
even a few drops — will hide a polyi^us by obscuring its characteristic 
color. To wi^De away the blood about fifty swabs of absorbent cotton 
mounted on applicators are needed during the operation. The appli- 
cation of adrenal extract before this will aid considerably in control- 
ling the hemorrhage. Elderly patients with atheromatous arteries are 
liable to secondary hemorrhage, which may come on an hour or two after 
the operation. Eemoval of the angiomatous variety of polypi may be 
attended by such profuse bleeding that packing of the nasal fossa be- 
comes necessary, especially if the growth has not been removed at its 
origin. 

To eradicate the growths entirely it is necessary that the patient's 
nares be inspected at intervals of several weeks for a period of some 



NASAL TUMORS. 



339 



months. Tliis T\'ill enable the surgeon to remove little tumors as they 
sprout until no more appear. Purulent nasal discharges and other 
sources of irritation suspected as causes of the disease must be removed, 
and sinus disease or carious bone as possible factors in the production of 
polypi must be remembered. After the polyi)i have been removed the 
patient should cleanse the nose once or twice daily with a wash of sodium 
bicarbonate, a teaspoonful to a pint of lukewarm water. 

Fig. 128. 




Papillary tumors of the nose ou the middle and lower turbinals. (Heymann.) 

Antisepsis and healing will be promoted by insufflation two or three 
times daily of a powder containing twenty per cent, of boric acid, fifty 
per cent, of iodol, and sugar of milk sufficient to complete the mixture, 
together with the use of a si)ray containing about one minim of oil of 
wintergreen, two minims of carbolic acid, and three minims of oil of 
cloves to an ounce of oleum petrolatum album. If secretion be profuse, 
ten minims of terebene may advantageously be added. 



^"ASAL FIBROUS POLYPI. 

Synonyme. — Fibromata of the nares. 

These connective-tissue growths are closely related to mucous polypi. 
Their histological structure differs from that of the mucous polypus 
simx)ly in the x)roportion of connective tissue composing their stroma. 
In the fibrous polyx)us this is comj^osed of connective-tissue fibres 
densely crowded together, so that interstitial spaces hardly exist. Elas- 
tic fibres are found in good proportion, while blood-vessels are, as a 
rule, sparingly present. The epithelial covering is identical with that 
of the mucous polypus. These growths are rare, and spring from the 



340 DISEASES OF THE NOSE AND NASOPHARYNX. 

submucous connective tissue, or from the outer layer of the periosteum 
or perichondrium. They are commonly located in the posterior third 
of the nares, or the roof of the nasopharynx, or on the superior or 
middle turbinated body. They are very liable to become oedematous or 
the seat of inflammatory processes 5 they are harder than mucous polypi, 
and, as a rule, bleed more readily. They are to be removed by the same 
methods as those employed for the mucous polypi, with this difference, 
that their dense, tough structure makes the galvano- caustic snare pref- 
erable to the steel-wire loop. 

NASAL PAPILLARY TUMORS. 
Synonyme. — Papillomata of the nares. 

The normal mucous surface of the nose contains no papillae except 
in the nasal vestibule, and therefore is but little predisposed to the for- 
mation of papillomata, which are rarely found in the nasal fossae, though 
the}' are more common than the fibromata. 

Fathology. — PaiDillomata are usually found on the lower turbinal, but 
they are also found on the septum, the middle turbinal, and the nasal 
floor. Moritz Schmidt has seen them chiefly on the septum, just back of 
the nasal vestibule. 

The surface of the growths x^resents varying appearances If the 
papillse be small, there is a resemblance to cutaneous warts ; if they be 
large, the tumor acquires a shaggy look. N'asal papillomata may form 
pedunculated tumors, or exist as flat growths which spread over the sur- 
face. The consistency of the tumors varies from gelatinous softness to 
true warty hardness, the latter being the usual one. The largest growths 
seldom exceed a hazel-nut in size. They are generally small and soli- 
tary, but may extend over a large surface, as, for instance, the whole 
free border of a turbinal. Microscopically, these formations resemble 
laryngeal papillomata, and have thick pavement epithelium. 

Symptoms. — The small size of these growths prevents them from 
creating much disturbance except occasional nose-bleed. They may be 
found accidentally, or cause obstruction to breathing, which leads to their 
discovery. 

Diagnosis. — Growths resembling i)apillomata are found at the pos- 
terior end of the lower turbinal in hypertrophic rhinitis. The surface 
here is merely corrugated, not warty, and no true papillae are found. 
Growths in the nose having the general appearance of papillomata, but 
possessing only a thin epithelial covering, are usually lipomatous or 
fibrous in character. 

Frognosis. — Papillomata have a tendency to spread and to recur if 
removed. 

Treatment. — The growth may be destroyed with nitric, acetic, or 
chromic acid, the cutting forceps or curette, or the galvano- cautery. In 



NASAL TUMORS. 341 

one obstinate case all of these methods were tried unsuccessfally, as the 
warts repeatedly returned in from four to six weeks after each removal. 
Finallj^ the patient was given a strong tincture of thuja occidentalis, 
which he applied to the i3art two or three times daily. This, with a few 
aiDplications of chromic acid, finally eradicated the disease. 

NASAL VASCULAR TUIMORS. 
Synonjrmes. — Bleeding polypus of the septum, angioma cavernosum nasi. 

These growths are found principally on the anterior i)art of the 
septum, either low down near the nasal floor or higher up opi)Osite the 
middle turbinal. They also occur on the lower turbinal, their size vary- 
ing from that of a lentil to that of a tumor large enough to occlude the 
nasal passage entirely. Their surface is usually smooth, but may be 
granular, and their color is generally deej) bluish red. The consistency 
of the growths is firmer than that of the mucous polyi)i, but their sub- 
stance is very friable, so that firm pressure on a probe may cause it to 
enter the tumor. Xasal vascular tumors may have a broad base or be 
pedunculated. Microscopical examination shows the epithelial covering 
to be Identical with that of the region from which the growth has 
sprung. The stroma consists of loose connective tissue surrounding the 
lumina of many large cavernous veins of irregular or oval shape, while 
arteries are sparingly present. These lacunar veins are found in greatest 
numbers in the deei3er parts of the growth, and may form a large part of 
its substance. The etiology is unknown. 

Symptoms. — The chief complaint of the patient is of frequent spon- 
taneous nose-bleed, often of such severity that the loss of blood is 
alarming. Examination of the nares shows a tumor presenting an 
appearance much like that of a polyj)us ; differing from it, however, in 
that it has a deep red color and an unusual seat on the septum or, rarely, 
on the lower turbinal. Touching it with a probe or seizing it with the 
forceps may start a hemorrhage that nothing but tamponing of the naris 
will quell. Cocaine has little effect on the bleeding or the size of the 
tumor. 

Diagnosis. — The color and seat of the growth, together with the ready 
hemorrhage, will distinguish it from a mucous polypus, but not so read- 
ily from sarcoma, especially as the latter is often found on the septum, 
bleeds easily, and has at times a pedunculated shape. The microscope 
may be needed for diagnosis. 

Treatment. — If pedunculated, the growths may be removed with the 
snare, though severe bleeding usually accomj)anies the oiDeration. It is 
best to use the galvano-cautery snare and employ a red heat with slow 
constriction. If the growth cannot be caught with the loop of the snare, 
it may be destroyed with the galvano-cautery. Even here the bleeding is 
liable to be so great that the operation has to be interrupted and renewed 



342 DISEASES OF THE NOSE AND NASOPHARYNX. 

at intervals of about ten days, the growth being thus removed piecemeal, 
while the nasal fossa is kept plugged with lint to prevent return of hem- 
orrhage. Nasal cutting forceps cannot be used unless the tumor be very 
small, as the bleeding after the first cut would make it impossible to con- 
tinue the operation. 

NASAL OSSEOUS CYSTS. 

Etiology. — The presence of cavities in the anterior end of the middle 
turbinal is not infrequent, and is simj)ly an anatomical abnormality, un- 
less the bony walls of this cavity distend and form a cyst. 

Pathology. — These bony cavities are generally seated in the anterior 
end of the middle turbinal, but have also been found back of this in the 
same bone or in the superior turbinal. They have a smooth globular 
shape, and vary in size from small cavities in the bony tissue, which 
cause no symptoms, to cysts that are as large as a hen's egg, and have 
been seen to protrude externally. Even if of moderate size, about that 
of a cherry, they crowd on the septum, forcing it into the other nostril, 
and in this way have in some instances produced entire occlusion of the 
opposite nasal fossa. The osseous cyst is also liable to press down the 
lower turbinal, and may reach the nasal floor. Exophthalmos has also 
been caused by pressure on the orbital wall. The osseous cyst represents 
an ethmoid cell that has been displaced into an unusually low situation. 
The outer covering of the growths may consist of thin, but normal, 
smooth mucous membrane covered usually with pavement epithelium, or 
mucous polypi may hide the bony cyst and grow from its surface. Its 
inner lining is also thin mucous membrane with ciliated epithelium. 
Polypi have been found within the cyst. The bony plate is delicate, and 
has a layer of periosteum on each side containing many osteoblasts. The 
contents of the cysts may be air, viscid fluid, or pus, as these cysts fre- 
quently suppurate. 

Symptoms. — In addition to the nasal occlusion caused by the cyst, 
the pressure of so firm a body on the neighboring parts causes headaches 
of severity much greater than common. Intense facial neuralgia may 
occur. Migraine, vomiting, dyspnoea, partial loss of consciousness, and 
other marked nervous symptoms may be causes of complaint. 

Inspection shows a smooth globular tumor, generally with normal 
thin mucous covering, pressing on the septum and perhaps forcing it 
more or less into the other naris. The tumor may reach such a size as to 
hide everything else from view. When opened it has been taken for the 
accidentally exposed cavity of the antrum. 

Diagnosis. — This may present some difficulty when the tumor is hidden 
by polypi, and its firm structure also makes it liable to be mistaken for 
osteoma. Opening the tumor will make the diagnosis clear. 

Prognosis. — The tumors are apt to grow to a large size, displacing 
important structures and causing great suffering. 



NASAL TUMORS. 343 

Treatment. — Operation may be undertaken with the steel- wire loop, 
the galvano-cautery snare, or, if this cannot be applied, the growth may 
be taken away in pieces with nasal cutting forceps. 

NASAL BOXY TUMOES. 
Synonyrae. — Osteomata of the nose. 

Patliology. — The shape of these tumors is ovoid or irregular, and 
dei)ends much on that of the cavity in which they have originated, so 
that their surface may be smooth or lobulated. 

There are two varieties of osteoma, the eburuated form, which has 
an ivory-like hardness, and the sponr/y or cancellous variety. Spongy 
osteomata have an outer com^^act shell of greater or less thickness. The 
hard variety may be so dense that it cannot be penetrated bj' cutting for- 
ceps or the nasal saw. Cancellous osteomata present the structure of 
cancellous bone with trabecuhe radiating from the centre. The vas- 
cular supply of the growth varies, but even the ivory -like osteomata have 
many blood-vessels, while the spongy growths have a copious blood- 
supply. 

The outer surface of the osteoma is covered with mucous membrane, 
often thinned by the distention due to increase of the tumor in size. 
Osteomata may be attached to their origin by a bony connection or 
mucous membrane and connective tissue forming a pedicle, or the tumor 
may have no connection with its surroundings. The base of origin 
varies and is not always easy to determine. The growths have been 
found originating from the ethmoid bone, the vomer, the lachrymal bone, 
the accessory sinuses, and other parts of the framework of the nasal 
cavity. The size of the neoi)lasm varies from that of a pea to that of a 
goose-egg. The tumors lie firmly wedged in by their surroundings even 
if they have no connection with them. Though of slow growth, they 
resistlessly i)ush aside all normal structures in their way or destroy them 
by atrophy. In this manner the septum is forced over and the orbit, 
sinuses, and pharynx entered, while nasal occlusion finally becomes com- 
plete. When the osteoma originates from the ethmoid or lachrymal 
bone it soon forms a protrusion at the inner canthus. The tumors have 
been known to grow for from ten to twenty years before removal. 

Symptoms. — At first these are slight, nothing being noticeable beyond 
itching, mucopurulent discharge and a tendency to nose-bleed. As the 
tumor grows the nose begins to feel full with a sense of weight, respira- 
tion is impeded, and the sense of smell is impaired. Added to these, 
pressure symi^toms begin to aj^pear, chief among which is i:)ain, either 
of a dull, deep-seated character or occurring in sharp neuralgic at- 
tacks. Small tumors, if in the course of a nerve, may cause intense 
pain. Pressure on the lachrymal duct may produce epiphora with 
dacryocystitis and conjunctivitis, and exophthalmos may occur, which 



344 DISEASES OF THE NOSE AND NASOPHARYNX. 

may lead to blindness. [N'asal mucous polypi frequently accompany 
osteomata. 

Inspection shows the tumor to be covered with bright red mucous 
membrane that in some cases may present ulceration. This necrosis 
of the tumor and ulceration of the surrounding mucous membrane may 
lead to fetid discharge. The growth gives to the probe the sense of 
absolute hardness, while a needle cannot be made to enter. 

Diagnosis. — Osteomata may be confounded with exostoses, rhinoliths, 
or malignant growths. At the outset they may be distinguished from ex- 
ostoses by their movability, and later by their different form, larger size, 
and darker color. Ehinoliths may be distinguished by the absence of 
mucous covering, and by the ease with which their surface is broken or 
crumbled by a strong nasal i)robe or forcei)S. Malignant tumors grow 
much more rapidly, are usually very soft, and in all cases can easily be 
punctured by the needle. Like osteomata, they cause extreme pain and 
an offensive discharge. 

Frognosis. — If the tumor be seen early enough, it may readily be re- 
moved through the natural passages, but, when large, external incisions 
are necessary and scars remain, unless it can be destroyed by a dental 
burr. There is no tendency to recur. If the growth be not arrested, it 
may lead to the gravest symptoms on account of pressure on neighboring 
structures of importance. 

Treatment. — Bony nasal tumors often necessitate operations of a gen- 
eral surgical nature in order to gain sufficient room for their removal. 
Osteomata composed of spongy bone may be crushed with strong for- 
ceps or cut in pieces with nasal bone- forceps. This cannot be done to the 
harder tumors, which must be ground away with dental burrs or perfo- 
rated with trephines driven by the dental engine. When a sufficient 
number of cores have been taken out in this way the bony mass may be 
broken with forceps. 

NASAL CARTILAGINOUS TUMORS. 
Synonyme. — Chondromata. 

Fatliology. — Chondromata occur more rarely in the nose than osteo- 
mata. Unlike the latter, their attachment is generally broad, and they 
are correspondingly immobile. They present a smooth, rounded surface, 
covered with reddened mucous membrane that is otherwise normal. In 
rare instances the tumors are surrounded by a bony shell. Microscoj^ic 
examination of the growths shows hyaline cartilage, fibrocartilage, or 
possibly a mixture of the two, or connective tissue may predominate. 
Blood-vessels are absent in the cartilaginous tissue. Chondromata may 
originate from the ethmoid bone, the outer wall of the nasal cavit;y^, or 
the accessory sinuses, but by far the commonest source of origin is the 
anterior j)art of the septum. The source of growth is the periosteum, 
the perichondrium, or the bony parts of the nose. 



NASAL TUMORS. 345 

Symptoms. — Chondromata occur only during the first twenty years of 
life. The symptoms are identical with those of osteomata. with the 
exception of the tendency to nose-bleed ; fetor of discharge is also gen- 
erally absent. 

Diagnosis. — Cartilaginous growths, when large, are liable to be mis- 
taken for fibrous polypi, malignant growths, exostoses, or osteomata. 
Practically, fibromata may be excluded because of their rarity. When 
present, they bleed more easily and are less dense than cartilaginous 
growths. Malignant tumors are softer, bleed easily, and grow rapidly. 
By inspection the surgeon can readily distinguish exostoses and ecchon- 
droses as being simi^le outgrowths. Bony tumors are harder and can- 
not be penetrated by the needle like cartilaginous growths. 

Prognosis. — The chondromata have a decided tendency to recur. 
Growth is slow bat steady, and the consequences the same as those of 
osteoma. 

Treatment. — Extirpation, preferably with the galvano-cautery snare, 
is the only treatment. As operations on the tumors cause but little 
bleeding, the latter may be reduced by cutting with the knife, nasal 
saws, or cutting forceps. 

XASAL 3IALTGXANT TUMORS. 

These present two classifications, — viz., sarcoma and carcinoma. 
Sarcoma occurs more frequently than the malignant growths of ej)ithelial 
origin, and is i>eculiar to the earlier decades of life, while carcinoma is 
found generally in people of advanced years. If non-malignant tumors 
are transformed into malignant ones at all, it is an occurrence of extreme 
rarity. 

Fatliology. — Sarcoma may be found as fibrosarcoma, also called spindle- 
celled sarcoma, myxosarcoma, round-celled sarcoma, melanosarcoma, and 
giant-celled sarcoma. This list also represents the order of the frequency 
of their occurrence. Closely allied to sarcoma is endothelioma. 

The favorite location of sarcoma is the septum, especially at its an- 
terior part, and next in order of occurrence are the ethmoid region and 
lateral nasal wall, in the tract chiefly of the middle and also of the lower 
turbinal. Sarcoma is also liable to make the accessory- sinuses its start- 
ing-point. Endotheliomata almost invariablj' begin in the ethmoid bone, 
and are, as a rule, outgrowths from bony structure. 

A tumor leading from the innocent ei)ithelial growths to the malig- 
nant ones is adenoma or adenocarcinoma, comx^osed of convoluted gland 
tubules with decidedly destructive and malignant tendencies in some 
cases, while in others they may be non-malignant. Carcinoma occurs 
as epithelioma, cylinder-celled carcinoma, and carcinoma with cells of 
nondescript character. Carcinoma, like sarcoma, has its favorite seat 
of attachment to the anterior part of the septum, but often originates 
from the sphenoidal cells, the ethmoidal cells, and the maxillary sinus, 



346 DISEASES OF THE :K0SE AND NASOPHARYNX. 

while it is also found on the turbinals. The rapid disintegration of the 
growth soon hides its origin. Sarcoma generally has its source in the 
periosteum, the perichondrium, or the bone, and may be of myelogenic 
origin, having for its starting-point the interior of the osseous portions 
of the nose, but carcinoma always originates in the mucous membrane. 
The histological character of these malignant growths is like that of those 
of the same kind occurring in other parts of the body. 

Symx^toms. — Occlusion of the nares by sarcoma occurs early and be- 
comes comi)lete. Signs of distention of the nasal cavity soon follow, so 
that x)ortions of its skeleton are forced outward. The alse nasi are thus 
thrust farther apart, the orbit encroached upon, and the eyeballs dis- 
placed outward, forward, or backward, causing hideous facial deformities. 
The tumor not only forces the bones aside but softens and perforates 
them, leading to their absorption. In this way sarcoma of the nasiil 
roof penetrates the cranial cavity. If this occur in the region of the 
frontal convolutions the cerebral symptoms maj^ be slight, but if the per- 
foration take place farther back in the parts of the cranial cavity situ- 
ated above the body of the sphenoid bone, there soon appear symptoms 
due to pressure on the ojDtic nerves, the abducens nerve, the third cranial 
nerve, and others in this region, involvement of the fifth cranial nerve 
resultiug in violent neuralgias. If the opening into the cranial cavity be 
established too far forward to interfere with the nerves mentioned, the 
first evidence of the penetration of the growth may be a sudden menin- 
gitis or abscess of the brain, or the symi)toms of gradually increasing in- 
tracranial pressure may be established. Sarcoma may penetrate the orbit 
through the lachrymal bone or the ethmoidal cells. Sarcomas or carci- 
nomas of the maxillary sinus at times cause no symj^toms until too large 
for that cavity-, or they are, early in their course, the source of empyema 
of the antrum, that maj' be diagnosed while the tumor is overlooked 
until it has attained sufiicient size to cause i)rotrusion of the wall of the 
maxillary sinus, or until it has made its appearance in the nasal fossa, 
^ose-bleed, often of a serious character, is apt to be an early and per- 
sistent symptom of sarcoma, while sloughing and ulceration occur late 
in the disease and are not prominent features of its course, as in 
carcinoma. 

In sarcoma inspection shows the naris blocked by a tumor, or in some 
cases this may be seen even protruding externally. The consistency 
of the growth in fibrosarcoma is tough ; in round-celled sarcoma soft, 
very friable, and in some cases sloughing. Fibrosarcoma is of a i^ink, 
often whitish, hue, while round-celled sarcoma is deej) red. Vascular 
tumors are dark or bluish red. The nasopharynx may be so filled with 
tumor-masses as to be closed for insi)ection by posterior rhinoscopy, while 
portions of the tumor may be visible below the soft palate. 

Carcinomata do not have the tendency to displacement of surrounding 
structures peculiar to sarcoma, but generally ulcerate as fast as they grow, 



NASAL TUMORS. 347 

SO that there is absence of normal tissues due to the ulcerative action 
of the neoplasm rather than any great quantity of tumor formation. 
Epistaxis is far less common in carcinoma than in sarcoma, and is gen- 
erallj^ due to mechanical lesions of the growth. The chief symptom in 
carcinoma is its tendency to ulceration and sloughing with the putrid 
discharge accompanying these conditions. The breath, therefore, soon 
acquires a pestilential odor. In most cases the cranial cavity is soon 
l^euetrated hy the growth, and meningitis or brain-abscess results. Car- 
cinoma of the sinus maxillaris readily ulcerates into the nasal fossa, 
making both cavities one. In nasal carcinoma pain is a prominent 
feature, and is often of a neuralgic character. Inspection in carcinoma 
shows a ragged, ulcerated growth tliat bleeds when touched and is cov- 
ered with sloughing tissue. This growth is seated deep in the nose, or 
on the septum or nasal A^ault, and is usually accomx:>anied by defects in 
the normal tissues of the nasal fossae, due to its destructive advance. 

Endothelioma has much the api^earance and character of the soft 
sarcomata. The nasal passages are filled with a rai^idly growing, fungous, 
friable mass of a grayish- pink color, whose tissues offer no appreciable 
resistance to instruments, but are the source of free hemorrhage as soon 
as wounded. Recurrence is rapid and the tendency to penetrate neigh- 
boring cavities great. 

Diagnosis. — In the earlier stages combination with mucous polypi or 
pol^T^id hyperplasia of the mucous membrane often makes the diagnosis 
of nasal malignant tumors difficult. The irritation they create causes them 
to be surrounded b}^ mucous membrane in a state of chronic inflamma- 
tory oedema with polypoid formations, or else they excite suppuration 
of the sinuses and i^eriostitis or perichondritis which lead to polypus 
formation with obstinate tendency of these growths to letui-n. As nasal 
mucous polypi are frequent, they may also exist independently in a nose 
that has become the seat of malignant disease. Occurring from what- 
ever cause, the i^olypi hide the malignant tumor from view until, after 
their repeated removal, the sarcoma or carcinoma begins to be apparent 
on account of its extension. Some sarcomata early in their growth 
much resemble polypi. Malignant tumors are to be suspected in con- 
nection with polyi^i when there is a fetid discharge from the nose with- 
out atrophic rhinitis or sinus disease to account for it, and when with 
polypoid growths considerable deformities of the nose occur due to 
distention of its bony framework with displacement of neighboring parts. 
This seldom happens in connection with simple mucous polypi. Histo- 
logical appearances of sarcomata are often misleading because of the 
resemblance of their structure to that of some forms of mucous polypi. 
Carcinomata are more readily recognized under the microscope. Tuber- 
cular or sj'philitic growths may resemble malignant tumors. Like these, 
tuberculous tumors are most often seated on the anterior part of the 
septum and turbinals. Histological examination will rev^eal the tuber- 



348 DISEASES OF THE NOSE AND NASOPHARYNX. 

cular tissue, and the involvement of other organs helps the diagnosis. 
Syphilomata are much harder to diagnose, as microscopically they re- 
semble round- celled sarcoma, but the free use of potassium iodide will 
make the diagnosis clear. 

The slow growth and hardness of osteoma and chondroma and the 
absence of ulceration are the chief points in their diagnosis. Bleeding 
polypi of the septum are differentiated by their usually remaining 
stationary in size and their generally pedunculated form. Ulcerated 
carcinomata may be mistaken for tertiary syphilitic ulcers, but there is 
generally some amount of tumor formation present in carcinoma, and 
microscopic examination of an excised piece will make the diagnosis 
certain. Ehinoliths and foreign bodies are often surrounded hj exuber- 
ant granulations, and are accompanied by a foul discharge. As carci- 
noma may leave fragments of bone bare and necrosed, diagnosis may 
be difficult. Cleansing of the nose and the local use of cocaine will aid 
in differentiation by facilitating inspection. 

Prognosis. — This is unfavorable in sarcoma unless its radical removal 
be possible. In this case the prognosis as to recurrence of the growth 
varies according to its histology. Spindle-celled sarcoma is least apt to 
return. Sarcomata growing from the medullary cavity of the bones, 
especially the giant- celled forms, permit a relatively good prognosis, 
and this is also true of melanosarcoma as occurring in the nose. The 
round-celled variety of sarcoma is the most malignant. As to the possi- 
bility of radical removal of sarcomata, those occurring on the septum 
are the most accessible and therefore most capable of complete extirpa- 
tion, those seated on the lateral wall of the nasal fossa are less favorably 
placed for operation, while those growing from the nasal roof or eth- 
moidal cells furnish a bad prognosis, as thorough removal is generally 
impossible. In nasal carcinomata the outlook is absolutely bad. 

TrecdmenL — ^When the growth is pedunculated, or it is desirable simply 
to remove portions for palliation of the disease, the gal vano- cautery 
snare offers the best means for operation if it can be applied. In other 
cases the sharp spoon may be employed, it being understood that under- 
taking to remove even portions of the tumor is not a trifling matter, is 
sure to be accompanied by severe hemorrhage, and is liable to be fol- 
lowed by septic inflammations. In those cases in which the cranial 
cavity has presumedly been penetrated by the growth, all operative in- 
terference, even of a palliative nature, is better avoided. In most cases 
the methods of approach ofl'ered by general surgical operations have to 
be employed in order to gain access to the growth. Sarcomata offer 
the best chance for oj)eration, as mentioned in the prognosis, while 
carcinomata are practically inoperable. 

Operations generally show the tumor to be of far greater extent than 
inspection has led one to believe. 



CHAPTEE XL 

SYPHILIS AXD TUBERCULOSIS OF THE XOSE. 
SYPHILIS OF THE NOSE. 

Syphilis may invade tLe nose in its iDrimary, secondary, or tertiary 
forms, and is often of the congenital variety. Its manifestations vary 
from those of an acute coryza to the entire destruction of the nasal in- 
terior. For reasons unknown to i:>athology, the nose is a frequent seat of 
the destructive forms of syj)hilis. 

Fathology. — Hard chancre is, very seldom found on or in the nose, as 
the chances for inoculation here are not so great as elsewhere. The 
disease is generally conveyed by the finger-nail, but sometimes handker- 
chiefs, towels, or other utensils may be its carriers. 

Primary syphilis of the nose may be external or be found within the 
nares. On the external nose it usualh^ appears as a flat induration of 
moderate size, and Avithin the nose it is most often found on the septum, 
existing as a red, flat, hard growth, covered with purulent secretion and 
bleeding easily, while at the same time the external nose may be swollen 
and red, and coexisting fever and neuralgic pains indicate the gravity 
of the infection. The submaxillai-j^ and sublingual glands and those in 
front of the ear become indurated. 

In secondary nasal syphilis there may be found merely the conditions 
of an acute coryza 5 in other cases papules or macules up to the size of a 
pea, of the characteristic copi)er color, are found on the external nose, 
especially in the sulcus alaris, or where the nose joins the upper lij). In 
these locations they are aj)t to be fissured and have scabs crusting their 
surface. In the inner nose papules are seldom found back of the nasal 
entrance. On the mucous surface they present the usual patches of 
whitish, milky proliferation of the epithelium peculiar to secondary 
syphilis. 

The tertiary manifestations of syphilis in the nose are of far greater 
importance than those of the secondary stage because of their destruc- 
tiveness. Tertiary syphilis of the nose generally appears after the stage 
of gumma formation has passed into that of destructive ulceration. 
When it softens and breaks down the typical gumma leaves deep crater- 
like ulcers, with often onlj^ a narrow outlet, while diffuse sj^philitic 
infiltration ends in more superficial ulcerations of the serj^iginous tj^pe. 
This diffuse infiltration has a firm rubber-like consistency and dusky 
hue. Tertiary ulcers may penetrate to the periosteum and perichon- 
drium and cause death of cartilage or bone, or else these structures may 
necrose as the result of gummatous periostitis, perichondritis, or osteitis, 

349 



350 DISEASES OF THE NOSE AND NASOPHARYNX. 

the destructive process starting in the depths of the tissues and work- 
ing to the surface. Gummatous syphilitic infiltration quite often also 
attacks the external nose, causing brawny thickenings which may re- 
sult in destruction of portions of the organ when ulceration occurs. 
The extent of necrosis due to tertiary syphilis varies. In many cases 
the destructive changes are limited to a perforation of the septum, usu- 
ally its bony portion ; in others the perpendicular plate of the ethmoid 
bone or the vomer, or both, are lost. In cases of still greater severity the 
entire septum and turbinals are destroyed, or to the loss of all the bones 
of the nasal interior is added perforation of the hard palate or complete 
loss of this with destruction of the soft palate as well. This extensive 
necrosis of the bony structures occurs in the type of syphilis called 
malignant, a form of tertiary syphilis which may even result in death of 
the sphenoid or ethmoid bones, with opening of the cranial cavity, men- 
ingitis, and brain- abscess. In some cases of nasal syphilis the inner or 
lower wall of the orbit is the seat of necrosis. Destruction of the septum 
alone does not cause the bridge of the nose to fall in ; this occurs when 
the nasal bones are also involved in the disease and become necrotic. 
The result is the type of deformity called the saddle nose, in which the 
nasal bridge is depressed while the tip is elevated. Cicatricial shrinkage 
of the parts within the nose may draw the cartilaginous portion of the 
external nose back tow^ards the nasal interior, making the rim of the 
apertura pyriformis appear as a ridge. 

Symxjtoms. — As is the case in all extragenital chancres, the symptoms 
of primary syphilis of the nose are apt to be very severe and the initial 
lesion of large size, while the infected lymph-glands may form large 
tumors. Chancre in the nasopharynx or posterior nares is difficult of 
detection. The symptoms of secondary nasal syphilis are those of an 
acute nasal catarrh of protracted course, and condylomata within the nose 
may cause obstructed breathing. 

Tertiary syphilis of the nose is apt to occur in the period between the 
first and third years after infection or during a second term between 
the fifth and fifteenth years after the disease has been acquired ; in fact, 
this is the time of greatest danger. The mildness of the symptoms 
accompanying tertiary nasal syphilis does not make the patient aware 
of the gravity of his affection, so that he is apt to present himself for 
treatment after irremediable destruction has occurred. 

The first symptoms are those of a chronic cold in the head, with 
stopping up of the nose, anosmia, and watery secretion which later 
becomes purulent, offensive, and bloody, and crusts, often of great size, 
are blown from the nose or hawked down the throat. The breath may 
become very foul, and neuralgic pains are felt radiating into the orbit, 
forehead, ears, and especially , the upper incisor teeth (nasopalatine 
nerve). The external nose and cheeks may be red and swollen, with 
oedema of the lids. 



SYPHILIS AXD TUBERCULOSIS OF THE NOSE. 351 

Inspection in primary and secondary syphilis shows those conditions 
described in the pathology of this article. In tertiary disease, if seen 
early enough, the surgeon may find the gumma or diffuse infiltration 
already described, usually seated on the septum, though any part of the 
nasal interior may be involved. The disease generally attacks the tur- 
binals in the form of a diffuse syphilitic infiltration that enlarges them 
until they touch the septum. This swelling resembles that of hyper- 
trophic rhinitis, for which it may be mistaken. It does not retract under 
the influence of cocaine, or only very slightly, and is apt to conceal ul- 
cerations farther back in the nose. The ulcerations in tertiary syphilis 
of the nose generally present the clean-cut border, yellow base, and hard, 
infiltrated surroundings of the syphilitic ulcer. 

When the disease begins in the x:)eriosteum or perichondrium the 
infiltrations or ulcerations described will not be seen, but a smooth, 
elastic swelling will present itself, usually on one or both sides of the 
septum, — a periostitic abscess. When this is opened, bare necrotic bone 
will be found at the bottom of its cavity. The majority of the cases of 
tertiarj' nasal syi^hilis which i^resent themselves have passed through 
these earlier stages of the disease, and seek treatment on account of 
the fetid discharge, offensive breath, and deformities resulting from the 
destruction of portions of the bones of the nasal cavity. To be able to 
examine these patients one must first cleanse the nose of the crusts and 
pus. In the milder cases a circumscribed necrosis may be invisible, and 
only discoverable with a probe. In some instances all ulceration may 
have ceased and the dead bone be enclosed in healthy granulating tissue ; 
in others one may find active ulceration, together with defects in the 
bony tissues, caused by the separation of sequestra. The necrosed por- 
tions of bone may lie loose in the nasal passages or be firmly attached to 
their location, and it may take a long time — even a year or more — before 
the dead bone becomes loosened and ready for removal. In those cases in 
which there is loss of the sei^tum, or septum and turbinals, the appearance 
of the nasal interior is that of a single large cavity lined with offensive 
dried secretion. One of the consequences of tertiary syphilis of the 
nose is atrophy of the mucous membrane and turbinals 5 so that in some 
patients, after the destructive process has run its course, conditions are 
found like those of atrophic rhinitis, and washing away of secretions 
shows merely an atrophied, not an ulcerated, mucous membrane. 

Perforation of the hard j)alate signalizes itself by a red swelling ap- 
pearing generally on one side of the raphe. This grows larger, becomes 
dusky in color, and finally a deep yellow ulcer forms in the centre, at the 
bottom of which the probe comes upon exposed bone. This process may 
continue to extend until the whole of the hard palate is destroyed. The 
rapid destruction of the bones of the nose in syphilis is due chiefly to the 
extension of periostitic abscesses, which separate the periosteum from 
the bone and cause its death over large areas. The necrosed bone has an 



352 DISEASES OF THE NOSE AND NASOPHARYNX. 

almost black color, and may be so large tliat it cannot be removed until 
it has been cut down. 

Diagnosis. — A general knowledge of the phenomena of syphilis is 
essential, as from local signs alone one cannot always make a diagnosis. 
The nature of a hard chancre of the nose may not be recognized until 
secondary symptoms make their api^earance. It has been mistaken for a 
malignant growth. The most valuable symptoms are the characteristic 
hardness and great swelling of the lymphatic glands. 

The secondary stage of the disease can be distinguished from subacute 
rhinitis by the appearance of mucous patches or condylomata in the 
nose, or, if these be absent, by syphilitic phenomena elsewhere. 

Tertiary syphilis of the nose is easy to recognize when the character- 
istic bony destructive processes have occurred, but earlier in the affec- 
tion the diffuse infiltration of the turbinals may resemble the conditions 
produced by hypertrophic rhinitis, and the history and results of treat- 
ment may be needed for diagnosis. Rarely, however, the turbinals alone 
are affected, and some ulceration of the pharynx or tonsils or other 
syphilitic manifestation will aid in distinguishing the disease. 

Syphilitic periostitic abscess of the septum may be mistaken for a 
simjDle abscess in this locality, and the history of the case and treatment 
alone can help to a decision. Lupus is distinguished from syphilis by its 
occurring at an earlier age than any form of syphilis except hereditary. 
In the beginning the peculiar reddish papules or tubercles of Iu^dus are 
quite distinct from any syphilitic manifestations, and later the marked 
preference which lupus shows for the cartilage is characteristic. The 
disease process is also much slower in lupus. 

As mentioned above, in the postsyphilitic stage there may exist a 
state of the mucous surface which is essentially an atrophic rhinitis, but 
the bony defects and septal perforations remaining after syphilis distin- 
guish it. Earlier in the disease, when it is in its active stage, the only 
thing that tertiary syphilis of the nose has in common with atrophic 
rhinitis is the odor, which is asserted to be of a different order in nasal 
syphilis from that occurring in ozsena. After removal of the secretions, 
the destruction wrought by syphilis, the characteristic ulcers, and the 
necrosed bone should enable even the inexperienced to make a diagnosis. 

Frognosis.— Everything depends on early recognition of the disease, 
as in all but the malignant cases treatment will promptly check it. That 
the disease is generally not jDromply recognized is proved by the number 
of noses seriously deformed by it. When there are ulcerations on the 
turbinals accompanied by great swelling, there may be cicatricial adhe- 
sions which unite the turbinals to the septum and prove very troublesome 
to treat. 

Treatment. — Syphilitic coryza requires no other treatment than the in- 
ternal administration of tonics and the local use of mild alkaline sprays 
or washes. Indeed, secondary symptoms usually require only mild con- 



SYPHILIS AND TUBERCULOSIS OF THE XOSE. 353 

stitutional treatment and touching of the condylomatous growths or 
mucous patches with tincture of iodine or silver nitrate. In tertiary 
syphilis treatment must be very energetic, as the disease can do enor- 
mous damage in a few days. ^Mien the symptoms are not very urgent, 
one can begin with small doses of potassium iodide, and gradually in- 
crease these until the i)atient is taking from thirty to sixtj^ grains three 
times a day ] but if the integrity of important structures be threatened. — 
as, for instance, if the hard palate seem to be in danger of perforation, — 
it is necessary to begin with doses of at least thirty grains of potassium 
iodide three times daily. Potassium iodide is best tolerated if given 
an hour or two after meals and diluted with a tumblerful of water or 
milk : this enables the patient to bear quite large doses from the start. 
In these threatening cases the drug should be rapidly pushed to the 
limit of physiological tolerance, and continued until some weeks after 
all syphilitic manifestations have ceased. Local treatment is extremely 
important. Periostitic abscesses should be opened early, to prevent 
the burrowing of the pus under the periosteum. Crusts and foul dis- 

FiG. 129. 




Ingals's nasal dressing forceps (three-fifths natural size). 

charges should be washed away two or three times a day with an alka« 
line solution containing one-fourth of a grain of potassium j^erDianganate 
to the ounce. Deep ulcerations are fiivorably influenced by the stimula- 
tion of a mild caustic application, and among these tincture of iodine 
seems to be the most effective. This will also promote the healing of 
superficial ulcers, though these will heal rax3idl3" enough without local 
treatment. So favorable is the influence of cauterizations on syphilitic 
ulcers of the mucous membrane that they frequently heal as the result 
of superficial burns with the galvano- cautery without any constitutional 
treatment. 

Apj)lications of strong tincture of iodine should be made daily for 
from ten to fourteen days until evidence of cicatrization appears, and 
then every other day for a week or more, and subsequently less often. 
"When the active advance of the disease has been checked, the remaining 
sequestra of dead bone cause a great deal of trouble. As long as necrotic 
bone is present in the nasal cavity the offensive odor and discharge will 
not cease, and yet it is not advisable to attemi)t to remove the offending 

23 



354 DISEASES OF THE NOSE AND NASOPHARYNX. 

fragments until they have become loosened from the surrounding healthy 
bone as the result of the formation of granulations, unless the necrosed 
mass be very large or cause extreme fetor. In some instances it maj^ 
take a year or even longer before the sequestrum is movable. When 
the fragment is loosened, its large size or shape may make it impos- 
sible to extract it without great force and laceration of the soft parts. 
In such cases it has been recommended to soften portions of the frag- 
ment by decalcification with commercial hydrochloric acid. This is 
applied by means of a copper probe with a roughened end to such 
portions of the sequestrum as can be reached. If the soft parts be 
burned by the acid, this is to be quickly neutralized with an alkaline 
wash. The softened parts can then be scraped off and the fragment 
reduced in size. 

When the piece of bone is loose in the nasal passages and is too large 
to extract, it can be held steady with nasal forceps while cores are drilled 
from it with the nasal trephine attached to the dental engin^. After it 
has been weakened in this way it can be broken up with nasal bone- 
forceps. Usually the latter is sufficient without the trephine. 

Mercury in some form may be employed as an aid to the action 
of potassium iodide. Inunctions are especially to be recommended, as 
their influence is rapid and the digestive organs are spared. In most 
cases of tertiary syphilis mercury is not as efficient as potassium 
iodide, but there are some which will not improve until mercury be 
employed. 

Coyigenital Syphilis of the Nose. — The more recent the syphilis of the 
parents the earlier will the affection appear in the offspring. Abortions, 
therefore, mark the earlier stage of the disease in the parents, while later 
premature infants may be born showing the marks of the disease. Chil- 
dren born at a period still later than this may not develop symptoms 
of syphilis until weeks or months after birth, and when the disease has 
progressed to the tertiary period in the i)arents, the offspring may not 
show any signs until tertiary symptoms occur years after birth. 

Symptoms. — Nasal symptoDis are among the most prominent of the 
features of hereditary syphilis. The earliest of these is syphilitic coryza, 
which makes its appearance generally from three to four weeks after 
birth. The nasal obstruction may prevent the infant's nursing, and so 
prove a serious danger to its life. Yellowish or brownish crusts are 
found adhering to the nostrils, which may be raw, cracked, and fissured, 
on account of the irritating discharge, that is at first watery, perhaps 
tinged with blood, and later becomes mucopurulent, finally drying into 
thick scabs, often of an offensive odor. The discharge causes the upper 
lip to become red, swollen, and excoriated, while the external nose is 
often congested and swollen. Syphilitic coryza is due to secondary syph- 
ilitic changes on the nasal mucous surface, notably syphilitic erythema. 
Tertiary disease is rare in the first year of life, but in some instances caries 



SYPHILIS AND TUBERCULOSIS OF THE NOSE. 355 

of the bones and cartilage occurs with, at times, disfigurement for life. 
An obstinate obstructive nasal catarrh occurring in infants is generally 
indicative of congenital syphilis, and indeed may for a time be its only 
symptom. The swelling of the mucous surface makes inspection of the 
nares usually impossible until the disease begins to improve. The in- 
fants are, as a rule, puny, senile in appearance, and present a roseola 
syphilitica, with crusting fissures of the corners of the mouth and rha- 
gades of the lips, loss of hair and eyebrows, and other signs of second- 
ary syphilis. Infants with congenital syphilis are by no means always 
atrophic in appearance, but may look plump and well nourished. 

Congenital tertiary nasal syphilis may make its appearance at any 
time during the first two decades of life, or in rare cases may even 
attack the patient later. Xearly all cases of the disease occur before 
puberty, however. Children affected with it are apt to present the so- 
called Hutchinson's triad of signs, — namely, notched upper incisor teeth, 
chronic keratitis or its remains, and deafness. In some cases secondary 
sym]3toms are absent, and the first manifestation of the disease is of a 
destructive tertiary character, the so-called syphilis hereditaria tarda. 
In congenital tertiary nasal syphilis the symptoms are apt to be very 
obstinate and intractable, and the disease may malignantly progress 
to a fatal termination, destroying all the tissues in its path, the hard 
and soft palate, the walls of the orbit, and the roof of the nasal cavity, 
in spite of heroic treatment with large doses of potassium iodide and 
mercury. 

Diagnosis. — Chronic coryza in infants is liable to be mistaken for this 
affection, but differs from it in the general appearance of the patient 
and the absence of secondary syphilitic symptoms. 

Frognosis. — The affection runs a chronic course, with little or no ten- 
dency to spontaneous recoA^ery. Eelapses are numerous, and, as men- 
tioned, the disease may assume a malignant form. Many of the children 
remain puny and die young, but some grow up to vigorous manhood or 
womanhood. 

Treatment. — Mercurials and potassium iodide are indicated internally, 
and local treatment is generally desirable, though in young children it is 
very difficult to carry out. Mackenzie prefers mercury with chalk, 
which he administers in doses of from one to two grains twice daily, to 
which he adds, if this cause diarrhoea, one grain of Dover's powder or 
an additional grain of chalk. Erichsen recommends the external appli- 
cation of mercury in the following manner^ proposed by Brodie : a 
drachm of mercurial ointment is spread upon a flannel roller, which is 
bound around the child's thigh just above the knee, the ointment next 
to the skin. This is renewed daily for two or three weeks, after which 
potassium iodide is administered in milk, cod-liver oil, or malt. Milk 
and water are the best vehicles for the administration of the drug to 
either children or adults. 



356 DISEASES OF THE NOSE AND NASOPHARYNX. 

TUBERCULOSIS OF THE NAEES. 

Tuberculosis of tlie nares is an affection of great rarity, and may be 
primary or secondary to tuberculosis elsewhere in the hodj. Though 
infection with the tubercle bacillus is the cause of both lupus and tuber- 
culosis of the nasal passages, the clinical features and pathological find- 
ings of the two affections are different. 

Fatliology. — In most cases the disease affects the septum, especially its 
anterior part. Tuberculosis may, however, affect any part of the nares, 
or appear in the nasoi)harynx. It shows itself in the form of a tuber- 
cular ulcer, tumor, diffuse infiltration, or as exuberant granulations. 
The last two forms are anatomically identical with the changes pro- 
duced by lupus, and it is but natural, considering their common origin, 
that the x>athological conditions produced by luj)us and tuberculosis 
should thus merge into one another. 

The ulceration may result from the breaking down of tubercular 
tumors or infiltrations or present itself as an ulcer from the start. Tu- 
bercular ulcers are most often secondary to jDulmonary tuberculosis. 
They are usually seated on the most anterior part of the cartilaginous 
septum, but have been seen on the turbinals and in the choan?e, where 
they are accompanied by great swelling and infiltration of the tissues. 
The typical tubercular ulcer may be as large as a cent, and is generally 
solitary. The form of the ulcers is round or oval, with irregular borders, 
and they are generally hidden by adherent scabs of muco-pus. When 
these are removed there is found the appearance typical of tubercular 
ulcers in other locations on irregular, worm-eaten borders, the floor of 
the ulcer being of a pale grayish-red color and sometimes covered with 
granulations. The borders may be level or prominently raised by tu- 
bercular infiltration, while miliary tubercles may be seen on the floor of 
the ulcer or surrounding it. They present a translucent grayish- or 
yellowish- white color, and, as they are constantly breaking down at the 
edge of the ulcer, they make its border irregular and ragged. Unlike 
the ulcerations of lupus, the tubercular ulcer shows no tendency to cica- 
trize. Though shallow at first, tubercular ulcers finally penetrate the 
cartilage and bone by erosion of these structures by granulation-tissue, 
leading to caries and perforations. This is the reverse of the course of 
necrosis in syphilis, which is generally due to primary i^erichondritis or 
periostitis, and perforates the mucous surface from within. 

The tubercular tumor is a form of tubercular tissue that has less 
tendency to disintegration than the tissue forming the floor of the 
tubercular ulcer ; therefore tumors of considerable size, even as large 
as a walnut, are formed before it breaks down. These growths generally 
originate from the cartilaginous septum, but may extend to the floor of 
the nose or the turbinals. They may be of broad base or pedunculated, 
and bleed readily when touched. The tubercular tumor, like other 



SYPHILIS AND TUBERCULOSIS OF THE NOSE. 357 

granulation neoplasms, is destructive. When tubercular new formations 
are destroyed by ulceration, tlieir remains present the appearances just 
described as tubercular ulcer. The tubercular tumor is the typical form 
of primary nasal tuberculosis, — that is, it often exists without tubercu- 
lar disease elsewhere. 

The third type of nasal tuberculosis is that of diffuse infiltration, 
which, like the other forms, is prone to attack the septum, but may also 
invade the turbinals. It forms firm, resistant swellings of a pale color 
with granular surface. Ulceration follows, and leads to perforations of 
cartilage or bone with the formation of fistula. 

The fourth type of tubercular nasal disease may be characterized by 
such an exuberance of granulations that the latter may hide ulcers, per- 
forations, and tumors. They are analogous to the fungous granulations 
found elsewhere in the body. Microscoj^ically, all these forms of nasal 
tuberculosis show the well-known structure of tubercular tissue. In the 
infiltrative and tumor form bacilli are sparingly present, but in the secre- 
tion fi^om the ulcerations they are apt to exist in abundance. 

Symptoms. — The ulcerations give rise to a purulent discharge, which 
is often offensive and usually collects in the form of scabs and crusts. 
Nose-bleed is an occasional occurrence. There is but little pain, and 
the course of the disease is slow and insidiously destructive, so that 
finally bone and cartilage yield to its advance, most cases, later in its 
course, showing perforation of the septum of varying extent. The nasal 
tuberculosis may be the i^rimary invasion of the organism by the dis- 
ease, and is generally followed by laryngeal or x>ulmonary phthisis. In 
the majority of cases nasal tuberculosis is preceded by tuberculous dis- 
ease elsewhere in the bodj'. 

Diagnosis. — To distinguish syphilis of the nose from nasal tuberculosis 
may be difficult, especially in the late forms of hereditary syphilis. The 
more rapid course of syphilis, the headaches and neuralgias apt to accom- 
pany it, and its i^roneness to attack the bones, while tuberculosis assails 
the cartilage, are qualities that help to distinguish it from tuberculous 
disease. Lupus generally progresses from the integument inward, and 
shows a tendency to cicatrize in places, while its course is extremely slow. 
As lupus and tuberculosis represent merely modifications of the same 
disease, the form of luj)us originating in the nose is often indistinguish- 
able from tuberculosis and resembles the infiltrative form of the latter. 

Tuberculomata disintegrate early by ulceration, and in this differ from 
the nasal neoplasms. Carcinoma may be distinguished by its protuberant, 
hard borders and the fact that it is usually a disease of later life. Sar- 
coma has a rapid growth. 

^[icroscopic examination of the tissues will not always lead to a 
clear understanding, as syphilitic infiltrations, sarcomata, hypertrophies, 
and other conditions may present histological appearances very much like 
those of tuberculosis. When the presence of tubercle bacilli can be 



358 DISEASES OF THE NOSE AND NASOPHARYNX. 

shown^ the diagnosis will become clear. The patient must always be 
examined for latent tubercular disease elsewhere, while his temperature 
should be systematically taken. 

Treatment. — When nasal tuberculosis accompanies advanced pulmo- 
nary consumption, or when the patient's vitality is low, an attempt at 
radical removal of the disease in the nose is useless. The treatment of 
the disease is mainly surgical, but even in the primary cases does not 
offer a guarantee against relapses, as it is almost impossible to remove 
every vestige of the tubercular tissue that extends far beyond its apparent 
limits in the form of miliary foci or lymphatic involvement. 

The first attention must be given to the general health of the patient, 
as his vitality is the chief weapon against the disease. It is impossible 
to make tubercular ulcers cicatrize while the patient is losing weight and 
strength. 

Tuberculous tumors should be removed with the cold or hot snare. 
Infiltration of tuberculous matter or fungous granulations are best de- 
stroyed by curettement with a sharp spoon. This is to be followed by 
the application of lactic acid in the strength of from fifty to one hundred 
per cent. This can also be applied to ulcers without previous scraping, 
if they be clean-cut in appearance and seem to have but little tuberculous 
tissue in their floors. 

Treatment of the ulcerated surface by carefully touching it from time 
to time with the galvano-cautery has been recommended and is advan- 
tageous in some cases 



CHAPTEE XII. 

EMPYEMA OF THE MAXILLARY AyTRU:M. 

Synonymes. — Sinuitis maxillaris acuta, sinuitis maxillaris clironica. 

Inflammation of the mucous lining of the antrum of Highmore may 
be acute or chronic. It is accompanied by a discharge of a serous^ 
mucous, mucopurulent, or purulent nature, often of offensive odor. In 
some cases the mucous lining of the antrum furnishes no secretion, the 
symptoms being caused by the swelling of the mucous membrane. 

Etiology. — Acute inflammation of the maxillary sinus often accom- 
panies acute rhinitis and influenza. In influenza the discharge is fre- 
quently i^urulent and the inflammation more severe than in simple acute 
rhinitis. 

The acute infectious diseases — pneumonia, typhoid fever, measles, 
scarlet fever, diphtheria, and small-pox — often give rise to acute inflam- 
mations of the antrum. Inflammatory^ disturbances in the neighborhood 
of the maxillary sinus are liable to involve it by extension ; this is 
especially the case in disease of the teeth of the upper jaw. Decay 
opens the pulp-cavity, clearing the way for infectious germs to follow the 
root canals to the periosteal lining of the socket of the root of the tooth. 
Here an abscess may form around the root, and if the lamella of bone 
separating it from the cavity of the antrum be thin, or, as in some cases, 
even wanting, infectious material may readilj' penetrate into the maxil- 
lary sinus, setting up an acute inflammation. It is not necessary, how- 
ever, that pus should actually enter the antrum from the root abscess. 
The septic inflammation maj' travel through the bone, which becomes in- 
flamed as a sequel to the periostitis. In this way a tooth whose socket is 
not situated under the antrum — as, for instance, an incisor tooth — may 
excite empyema by causing osteitis of the alveolar process ; similarly, 
periostitis or osteomyelitis of the upper jaw from other causes may give 
rise to empyema of the antrum. Disease of the roots of the first and 
second molars is most liable to be followed by sinuitis, as the bony cover- 
ing between them and the sinus maxillaris is apt to be thinner than in 
other places. The third molar and first bicuspid rank second in their 
liability to originate antrum disease. In rare cases the antrum extends 
as far as the cuspid tooth. In children the germs of the second teeth 
separate the bottom of the antrum widely from the teeth of the first set 
until second dentition, and up to this period empyema of the antrum is 
practically unknown. Eoot abscesses are generally accompanied by ab- 
sorption of the bone about them, a process which favors penetration 
by infectious material of the tissues separating them from the antrum. 

359 



360 DISEASES OF THE NOSE AND NASOPHARYNX. 

Dental cysts forming at the roots of teeth may suppurate and burst into 
the maxillary sinus, causing empyema. 

In the extraction of teeth injury has been done to the bony partition 
between the root socket and the floor of the antrum, especially if the 
tooth has been crowded towards the antrum in order to take a firm hold. 
In this way an opening has been established between the oral cavity and 
the antrum, with the possibility of infection by food particles, or else 
septic matter around the root has been forced into the antrum. 

Objects causing penetrating wounds of the antrum may create em- 
pyema, especially if they be infected or leave foreign bodies in the 
maxillary sinus. Ascaris lumbricoides has been known to enter the 
antrum through the natural opening. 

The causes of chronic empyema of the antrum include those of the 
acute disease, from which it often originates. 

Chronic empyema is found associated with atrophic rhinitis, and in 
some cases this ailment is to be regarded as a sequel to the empyema. 
Simple and malignant tumors of the antrum are quite sure to excite 
empyema. 

Fathology. — Acute inflammation of the mucous surface of the antrum 
presents the usual hypersemia of acute catarrhal inflammation elsewhere. 
The mucous membrane is reddened and congested, and has a marked 
tendency to form localized or general watery oedematous swellings, at 
times so great as to fill the cavity of the antrum. As the veins of the 
antrum pass through its narrow nasal orifice in the hiatus semilunaris, 
or else find their way through bony canals in its walls, it is plain that 
very moderate swelling of the soft parts lining these outlets will com- 
press the veins and cause oedema. Microscopically, the tissues of the 
mucous membrane are found infiltrated by leucocytes, sometimes very 
densely, while hemorrhagic extravasations may be jjresent. The ei)ithe- 
lium is generally found intact. When the secretion is purely mucous it 
may be of a thick, jelly-like consistency or thin and almost watery. 
Among the numerous micro-organisms found in acute catarrh of the 
antrum the most imx^ortant are the diplococcus of pneumonia, strepto- 
coccus, staphylococcus, and the bacillus capsulatus mucosus. In rare in- 
stances the mucous membrane may be covered with a false membrane in 
which the bacillus of diphtheria has sometimes been found. 

The pathological api)earances in chronic inflammation of the maxil- 
lary sinus do not differ from those of the acute variety until they have 
lasted a long time ; then formation of new connective- tissue growth takes 
place, and sometimes infiltrates the mucous and submucous tissues to 
such an extent that the lumen of the antrum is almost obliterated by 
their dense hyperplastic thickening. The tough fibrous structure of 
the mucous membrane is firmly attached to the bony tissue underneath. 
The surface of the lining of the antrum becomes rough and uneven, and 
is often covered with warty or polypoid excrescences. The periosteum is 



EMPYEMA OF THE MAXILLARY ANTRUM. 



361 



also affected by the process, and osteophytes and small bone-plates are 
found within the thickened submucous tissues. 

The exudation found in the cavity of the antrum is, as a rule, puru- 
lent or mucopurulent, but maj^ also be serous or mucous, as in acute 
sinuitis. Dei^osits of cheesj^ masses of inspissated leucocytes, fat-crystals, 
and other residual material may cover the walls of the antrum or even 
fill its cavity. All varieties of micro-organisms are found in chronic 
sinuitis of the maxillary sinus, — pneumococcus, staphylococcus, strepto- 
coccus, bacillus coli communis, bacillus capsulatus mucosus, bacillus 
pyogenes foetidus. They are not necessarih^ responsible for the continu- 
ance of the disease. The secretion is far more apt to be fetid in chronic 
inflammation of the antrum than in acute sinuitis. 

Fig. 130. 




Om 



An B 

Changes in the second stage of chronic empyema of the antrum of Highmore. (Heymann.) An, 
antrum ; Sf, sinus frontalis ; Ec, ethmoidal cells ; Om, opening of the maxillary sinus ; K, greatly 
thickened eburnated bony wall of the antrum ; B, thickened mucosa composed of cicatricial connec- 
tive tissue ; C, cysts. 



Symptoms. — The symptoms of acute inflammation of the maxillary 
sinus maj^ be mistaken for those of neuralgia of the superior dental or 
sui^ra- or infraorbital nerves accompanying an acute cold in the head, 
and it is probable that antrum disease is often not recognized because of 
its obscure symptoms. 

In the milder cases acute sinuitis of the antrum will cause but little 
distress, but in those of severer grades there are fever, seldom more than 
moderate, and pain, often of great severity. The x>atient's first sensa- 
tions are usually weight and distention in the ui^per jaw, but soon this 
changes to actual pain in this locality, — a pain which is apt to radiate into 



362 DISEASES OF THE NOSE AXD NASOPHARYNX. 

the teeth, the temples, or the orbit, causing photophobia and lachryma- 
tion, with, in some cases, pain in the eyeball. There may also be supra- 
orbital neuralgia, hemicrania, or headache. Sneezing, coughing, bending 
forward, — in fact, anything creating venous congestion in the head may 
greatly add to the pain. Swelling of the cheek, extending sometimes to 
the lids, with, in some cases, reddening of the surface, may occur. The dis- 
charge may appear at once in the nose or after several days, apparently 
forcing open the ostium of the antrum by pressure. When this occurs 
there is great relief from the pain, which maj^, however, return several 
times as the cavity refills. When the secretion bursts from the antrum in 
a sudden manner, it is apt at first to flow freely from the nostril, the char- 
acter of the outflow being that described above. When decayed teeth 
have produced the disease, the discharge is generally very offensive. 

Acute inflammation of the maxillary sinus lasts, as a rule, from one 
to three weeks, unless it merges into the chronic form. It may involve 
both antra, and one attack is liable to be followed by others. Unusual 
occurrences are oedema of the lids, conjunctiva, and cellular tissue of 
the orbit, with exophthalmos, and sometimes temporary diminution or 
loss of vision. 

The chronic form of emxDyema of the antrum may be latent, the dis- 
charge not having noticeable characteristics, while there are no subjective 
symptoms. In a typical case the patient's chief complaint is of the dis- 
charge, which is generally pus or muco-pus, but in rare cases it is serous 
or mucous. The position of the outlet of the antrum near its top makes 
drainage of this cavity imperfect, so that in the upright position it has 
to fill to the level of the ostium before discharge of secretion can occur. 
Accessory outlets, however, may exist, and are found just above the 
lower turbinal. Certain conditions which temporarily increase the flow 
of secretion have diagnostic value. Thus, if the patient lie on the healthy 
side or invert his head or bend forward, the fluid contents of the antrum 
may, for mechanical reasons, discharge more freely. A similar effect 
may be obtained with the Politzer air- douche or by aspiration produced 
by swallowing while the nose is closed with the fingers. The discharge may 
be so free that it comes dro]3 by drop, or so scanty that it dries into crusts. 
Swelling of the mucous membrane about the outlets or the ]3ressure of the 
polypi and hypertrophies so often found about them in this disease may 
impede the discharge, which will, however, slowly leak through in spite 
of these obstructions as soon as the pressure within the antrum, due to 
accumulated secretion, is sufficiently great. The discharge flows into the 
middle meatus, and from here may si)read forward or downward ujDon the 
nasal floor or back into the nasopharynx, which it may cover in fluid 
form or coat with scabs when it dries. Hypertrophies or polypi under- 
neath the middle turbinal may kee]) the pus from appearing in the 
forward part of the nose. The putrid odor and taste of the secretion are 
disgusting to the patient, and keei) him hawking, spitting, and blowing 



EMPYEMA OF THE MAXILLARY ANTRUM. 363 

his nose, and, if swallowed, the pus may nauseate him and cause vom- 
iting. The secretions may collect in the nasopharynx overnight, whence 
they are hawked with great difficulty. 

Through direct extension of the inflammation from the antrum, or more 
often by reason of the irritating nature of the discharge, the nasal mucous 
surface becomes diseased in about one-half of the cases of empyema of the 
antrum. This is especially the case in the purulent form of the disease, 
but may occur when there is serous, mucous, or no discharge. The 
nasal manifestations consist of hypertrophies of the mucous membrane 
and polypi which form about the outlet of the antrum in the hiatus 
semilunaris or on the processus uncinatus and the middle turbinal. 

Pain is not so prominent a symptom as in acute sinuitis. There may 
be a local aching and feeling of weight, but usually these are absent, 
while neuralgic pains are felt in the teeth, temple, eye, forehead, or one- 
half of the head. At times there is simply a headache, often of a severe 
character. These reflex neuralgic pains originate from the sensitive mu- 
cous lining of the antrum, and because of direct irritation of the branches 
of the superior dental nerves as they course along the walls of the maxil- 
lary sinus, the bony canals in which they are contained being in places 
devoid of their osseous covering. Mental symi^toms of empyema of the 
antrum are forgetful ness, inability to concentrate the mind, and sleepi- 
ness. Eeflex eye symptoms also occur : i)ain in the eyeballs, lachryma- 
tion, weakness of accommodation, and diminution of the acuteness of 
central vision and of the visual field. Hypersemia and neuritis of the 
optic nerve may occur. The sui^x^urative i)rocess may extend beyond the 
cavity of the antrum. Ulceration of its mucous membrane and inflamma- 
tion or localized necrosis of its bony walls usually precede this. It is not 
necessary that the bony wall of the antrum should actually be perforated 
by the pus, as the septic inflammation may pass through it by causing 
osteitis and periostitis. In this way abscesses beneath the cheek may form, 
or dangerous i^hlegmons of the sphenomaxillary fossa. Abscesses and 
fistulie of the hard palate occur. When the suppuration extends to the 
orbit, great swelling of the lids, chemosis, exoi)hthalmos, and partial or 
complete blindness result. The orbital abscess thus formed may burst 
through the lids or enter the cranial cavity by the optic foramen, leading 
to meningitis, or the orbital roof may be perforated or inflamed and give 
passage to infection, resulting in abscess of the frontal lobe. 

Dilatation of the antrum of Highmore due to the pressure of re- 
tained secretions is an occurrence of great rarity. The obliteration of 
the opening or openings is ordinarily caused by inflammatory thick- 
enings or cicatricial contractions of the mucous membrane surround- 
ing them, changes which are the result of the chronic sinuitis itself. 
Distention of the antrum is far more apt to occur as the result of slowly 
growing dental cysts, which in time fill the entire cavity of the maxil- 
lary sinus and dilate its walls. The same condition may result from the 



364 DISEASES OF THE NOSE AND NASOPHARYNX. 

presence of a mucous polypus in the cavity, but is more frequently caused 
by malignant neoplasms wbicb have their origin in it than by any other 
condition. 

Diagnosis. — The most important of the subjective symptoms in the 
diagnosis of empyema of the antrum is that of a unilateral fetid puru- 
lent discharge from the nose, often accompanied by the neuralgic pains 
mentioned, the discharge being increased by certain positions of the 
head. When these classic symptoms of the disease exist they strongly 
suggest empyema, and the patient's voluntary statements describing them 
may be so characteristic as to lead the surgeon at once to suspect the dis- 
ease. In other cases these symx3toms may be absent, or so obscured and 
overshadowed by those caused by the intranasal hypertrophies and the 
nasal mucous polypi resulting from the irritating discharge that the sur- 
geon is led to think of disease of the nasal passages rather than of the 
antrum. The most characteristic sign discovered by inspection is a flow 
of pus in the middle meatus, which is slowly or rapidly replaced after 
it has been wiped away, and which gives a foul odor to the swab used for 
the removal of the discharge. After changes of the position of the head, 
or the use of the Politzer air-douche, it may be found that the pus es- 
capes more freely. It may be necessary to remove polypi and hypertro- 
phies before inspection will show 
^^^^- ^^1- these characteristic signs. A valua- 

ble, but at times misleading, aid to 
diagnosis is furnished by transillu- 
mination. A three- to six- volt elec- 
tric light, enclosed in a small glass 

Ingals's electric lamp (one-half natural size). -, . j. -j. i • j_i 

For transillumination. ^^"^^ to prcvcut its bumiug the pa- 

tient' s mouth, is placed a short dis- 
tance back of his incisor teeth. He is then told to close his lips firmly, 
when his face will present a pink glow in the region of the cheeks, with 
darker shadows above. Under ordinary conditions his eyes will also 
appear as two faintly reddish spots, surrounded by the dark ring of the 
orbit. Under favorable conditions the pupils are visible as two faintly 
lighted disks. This examination is of value only if it take place in 
a dark room or closet, or under a dark cloth, as in photography. The 
current must be strong enough to make the light burn brilliantly white. 
The portions to be especially observed are the pupils and the region im- 
mediately beneath the lower border of the orbit. Should these parts 
appear illumined on one side of the face and dark upon the other, it 
does not necessarily mean that there is a collection of pus in the antrum, 
as unusual thickness of its bony walls, or smallness of its cavity, or an 
hypertrox^hic state of its mucosa, or asymmetry of the ui)per jaw, making 
one antrum smaller than the other, may cause the difference in illumina- 
tion. When the facial bones are strong and heavy, as they are apt to 
be in men, the illumination of the eye and infraorbital region may be 




EMPYEMA OF THE MAXILLARY ANTRUM. 



365 



Fig 




insufficient on both sides to permit transillumination to be of value as an 
aid to diagnosis. During the illumination the patient normally perceives 
a red glo^' in both eyes ; if he does not see it in one or the other, it will 
show that for some reason the light has failed to pass through the antrum 
on that side, and that empyema is a possible cause. It is, however, hard 
to locate the subjective sensation of the light sufficiently to tell whether 
one perceives it in one or both eyes. On account of their lighter facial 
bones, women are better subjects for transillumination than men. It is to 
be remembered that a dental plate will constitute an obstacle to the light. 
Taken alone, transillumination is of little value, 
but in combination with other signs of maxillarj" 
sinuitis it is of great service in confirming the 
diagnosis of empyema, and in obscure cases of 
nasal disease may lead one to suspect the exist- 
ence of pus in the antrum, and induce him to 
apply other methods of investigation. These are 
probing of the antrum, insufflation, irrigation, 
and aspiration. To pass a i3robe through the 
normal opening of the antrum in the hiatus 
semilunaris is possible in about two-thirds of || 
the cases. The probe to be emj)lo3'ed should be 
about one-twenty-fourth of an inch in thickness, 
and should have an olive-shaiDed point. It should 
be bent at an angle varjang between one hun- 
dred and ten and one hundred and eighty de- 
grees ; the bent extremity should be from one- 
fourth to five-sixteenths of an inch in length. 
The probe should be insinuated, beak upward, 
into the middle meatus about as far as the centre 
of the middle turbinal ; here the point should be 
turned outward at an angle of from ninety to 
one hundred and twenty degrees to a vertical 
line, when by moving it about a little it may 
be made to glide into the opening of the antrum. 
A valuable guide is the sensation obtained as 
the extremit}^ of the probe hooks behind the 

l^rocessus uncinatus. When the probe has been introduced, pus will 
sometimes flow out beside it. A fine silver tube, bent in the same man- 
ner as the probe, may next be iutrodnced, and used to blow secretion from 
the antrum by connecting it with an insufflator. If this be unsuccessful, 
it may be joined to a syringe and the antrum irrigated, so as to wash out 
the pus. It is better to use insufflation first, as, if the fluid contents of 
the antrum be serous, they will invisibly mingle with the irrigating fluid. 
If the antrum cannot be entered by the normal opening, a sharply curved 
trocar and canula or a curved hollow needle may be thrust into its cavity 



li 



Vohsen's transillumination 
lamp, with glass dome over 
it to prevent heating of mouth, 
and rubber cylinder to be 
slipped over light for illumina- 
tion of frontal sinus. 



366 DISEASES OF THE NOSE AXD NASOPHARYNX. 

through the middle or, better, the lower meatus. The needle enters the 
middle meatus more easily than the lower, but the latter is better for 
purposes of aspiration. The needle should be introduced at a point back 
of the centre of the loAver turbinal, as the bone is thin here and the ex- 
aminer avoids the lachrymal duct. Aspiration can be at once attempted 
through the canula, which should be fitted for attachment to a syringe. 
If, by reason of its viscidity or of cheesy masses that block the tube, this 
cannot be made to fill with pus, the surgeon may inject sterilized normal 
salt solution into the antrum, and on withdrawing this may find it mixed 
with pus. If the bone be too thick for penetration by the trocar, the 
opening may be made with a trephine driven by a dental engine. The 
opening is, however, hard to find with the tube after the trephine has 
been withdrawn. The application of cocaine to the lower or middle 
meatus by means of a cotton swab should i)recede all these manipulations. 
Sometimes the antrum is divided by a septum into two or more compart- 
ments, one only of which contains pus. In such a case the operator 
may penetrate the empty one, while its filled neighbor escapes. If he 
can exclude the anterior ethmoidal cells or the frontal sinus as the source 

Fig. 188. 




Kranse's trocar. 

of the pus appearing in the middle meatus, he may make an opening 
through the socket of a molar tooth after it has been extracted, or the 
antrum may be entered through its anterior wall above the space between 
the last bicuspid and first molar tooth. For this purpose a trephine or 
burr may be used. In this way the instrument may enter a pus-cavity 
that could not be reached from the nose. 

To differentiate empyemas of the maxillary from those of the frontal 
sinus or anterior ethmoidal cells is often difficult. The discharge from 
all these cavities flows into the same locality, the hiatus semilunaris, 
and appears underneath the middle turbinal, so that the presence of 
pus in this location is characteristic of disease of all these sinuses. Two 
or more of them may be suppurating at the same time, and it may be 
only after the discharge has been stopped from one that the surgeon 
discovers that disease remains in the other. Thus he may be able posi- 
tively to exclude suppuration of the frontal sinus or anterior ethmoidal 
cells only if, after he has drained and irrigated the antrum of High- 
more, pus ceases to appear in the middle meatus. If it be still found 
there, one must explore these other cavities in the manner to be mentioned 
with their description. When foreign bodies are in the nose, inspection 



EMPYEMA OF THE MAXILLARY ANTRUM. 



367 



and probing should make it impossible to mistake them for empyema. 
Tertiary syphilis of the nose presents, as a rule, ulcers and necrosis on 
both sides of the nose, and has only the foul discharge in common with 
empyema, to which it very rarely gives rise. Empyema of the antrum 
may coexist with atrophic rhinitis, and may in some cases cause it. In 
disease of the sphenoidal sinus the discharge appears in the superior 
meatus and is found in the nasopharynx. Tumors of the antrum gen- 
erally cause emjDyema, but distend the antrum when they have grown 
sufficiently, while simi)le suppuration very rarely does this. Dental cysts 
have generally no communication with the nose, so that when they are 
opened from the alveolus, fluids used for irrigation will not appear in the 
nasal cavity. In the rare instances in which they perforate the nasal 
wall of the antrum they do so in 
the lower meatus, so that the 
water injected into them will run 
into the nose in this situation. 
When dental cysts have been 
emptied they usually soon cease 
discharging. 

Frognosis. — Acute sinuitis gen- 
erally ends in spontaneous recov- 
ery, but may merge into the 
chronic form of the disease. 
Like suppuration elsewhere in 
rigid-walled cavities, chronic em- 
pyema of the antrum shows no 
tendency to spontaneous recov- 
ery. Left to itself, the disease 
usually continues for years or 
decades, presenting about the 
same symj)toms, while the nose 
gradually becomes occluded by 
hypertrophies and mucous pol- 
ypi. Even after the antrum has 

been opened by operation and irrigation employed the hypertrophied 
and degenerated mucous membrane may continue to secrete pus, while 
existing x)Ockets and recesses of the cavity keep up the discharge because 
imi)erfectly drained. In such cases radical operations which open the 
antrum broadly and permit packing and curettement may bring about 
recovery ; but even here, in some instances, all that can be attained is 
improvement. It is. therefore, well to be cautious in promising recovery, 
as this may be long deferred, require radical operations for its accom- 
l^lishment, or be impossible of attainment. A large proportion of cases, 
however, will get well as the result of drainage and irrigation, some 
speedily. The extraction of an offending tooth may have a favorable 




Transverse section through the antrum of High- 
more. (HejTnann.) am, antrum ; pm, position for 
puncture Avith trocar in middle, and pi, in lower 
meatus. 



368 



DISEASES OF THE NOSE AND NASOPHARYNX. 



influence. The most important thing to be considered is the condition 
of the mucous membrane of the antrum. Should this have undergone 
great pathological alterations, recovery will be impossible without radi- 
cal operation. The graver complications — abscesses of the orbit, menin- 
gitis, and brain-abscess — are, fortunately, very rare. In the majority of 
cases rational treatment of the empyema will be followed by disappear- 
ance of complicating symptoms, even blindness. 

Treatment. — The antrum offers four points of approach for therapeutic 
measures : the natural opening or its neighborhood in the middle meatus, 
the socket of a molar tooth, the anterior wall of the antrum above the 
roots of the molar and first bicuspid tooth, and the inferior meatus of the 
nasal fossa. 

In recent cases and in those in which there is no reason to think that 
the mucous membrane has suffered great pathological change, it is justi- 
fiable to hope that the disease 
Fig. 135. can be relieved by means of 

irrigations through the natural 
opening or by an artificial one 
made in its neighborhood in 
the middle meatus, as the wall 
of the antrum is very readily 
penetrated in this region. All 
polypi and abnormal thicken- 
ings of the mucous membrane 
are to be removed as a prelimi- 
nary, and it is essential that 
the natural opening of the 
antrum should be made as 
clear of obstacles and as unob- 
structed as in health. This is 
necessary even if the surgeon 
place the opening for irriga- 
tion in another part, as, if the normal opening be wholly or x)artly closed, 
the secretions find an obstacle to escape after the artificial one is allowed 
to heal. Therefore, if the region of the hiatus semilunaris be filled with 
polypoid masses and the processus uncinatus be hypertrophied, access 
to these parts must be gained by removal of the anterior end of the 
middle turbinal. For this purpose a blade of a pair of nasal scissors is 
inserted under the middle turbinal as high up and as far back as it will 
go along the junction of the middle turbinated bone with the external 
nasal wall, the direction in which the blade advances being upward and 
backward. The blades of the scissors are then closed, and the turbinal is 
severed from its attachment as far back as they reach. The loose piece 
is then divided from the remaining part of the turbinal by means of the 
cold snare. This exposes the infundibulum and hypertrophied processus 




Dental cyst entering the antrum of Highmore, 
sawed through in a transverse direction. (Heymann.) 
am, antrum ; ci, lower turbinal ; zc, dental cyst ; d, 
root of tooth from which the cyst originated. 



EMI'YEMA OF THE MAXILLARY ANTRUM. 



369 



uiiciuatus, which is next pierced with the blade of the scissors and its 
l^rojecting portion cut off. This operation exposes the infundibulum, 
which can then readilj' be cleared of hypertrox^hic masses by means of 
nasal cutting forceps, such as Griinwald's. If the natural openings be 
found too small; they can be enlarged with a small, strong, curved, sharj) 
bistoury, or artificial openings can be made in the same way. The 
X:>roceeding is not a formidable one, and is of great value whatever treat- 
ment is adoi)ted later. It is usualh' an essential preliminarj' to the diag- 
nosis and treatment of sinuitis of the frontal sinus and of the anterior 
ethmoidal cells. AVhen this exists, efforts to relieve emx^yema of the 

Fig. 13(3. 




^^'~'~M^m 




Lateral nasal wall. (Heymann.) ab, cut with scissors for removal of anterior end of middle tur- 
l)inal ; abc, piece to be removed with snare ; h, hypertrophy of lower turbinated body ; oss, opening of 
sphenoidal sinus. 



antrum may be futile until it has been removed, as the pus from these 
cavities flowing into the infundibulum penetrates the oiDening of the 
antrum and reinfects it. For the purpose of irrigation one of Hart- 
mann' s tubes or a silver tube bent at the proper angle, as described under 
diagnosis, is passed into the natural opening or the artificial one that has 
been made and attached to a large syringe. The stream of fluid has suf- 
ficient force to stir up and mix cheesy masses with itself and so remove 
them. The fluid used may be normal salt solution or one of potassium 
permanganate of sufficient strength to color water moderately pink. 
Strong solutions are to be avoided, as the lining of the antrum is very 
sensitive. In cases of greater obstinacj^ — those which do not speedily 

24 



370 



DISEASES OF THE NOSE AND NASOPHARYNX. 



recover as the result of irrigations through the natural opening — it is best 
to enter the antrum through the socket of a molar tooth, provided one 
can be found that is unsound enough to sacrifice, or the space left by 
a previously extracted tooth can be used. The socket of the first bicuspid 
may also be employed if the molars be sound and it is not, but the thick- 
ness of the bone above this tooth is generally greater than that above 
the molars. Opening the antrum through the socket of a molar is the 
most satisfactory procedure for the treatment of the majority of cases of 
empyema, as it drains the cavity at its lowest point and enables the 
patient to wash out his own maxillary sinus, while the intranasal methods 
of irrigation can be employed only by the physician. 

As a preliminary to the operation the route to be travelled by the 

drill is to be anaesthetized by the 
injection of cocaine with a hypo- 
dermic needle. The operation is 
very jDainful, and it is better to use 
general anaesthesia. The hemor- 
rhage during the ox)eration is in 
some cases great, even so much 
that it may be necessary to stop 
drilling and pack the canal to stop 
the bleeding. The opening should 
be at least a quarter of an inch in 
diameter, and can be made with a 
conical Brainard bone-drill or with 
a trephine or cutting burr attached 
to a dental engine. The distance 
to be drilled through varies greatly 
according to the thickness of the 
bone. When it is necessary to bore through an old alveolus that has 
filled up with bone, the road to the antrum may be a long one. The drill 
must follow exactly the direction of the socket of the tooth. If the drill 
be pointed too far forward, the antrum is missed and the cheek is entered j 
if too far inward, the drill is liable to appear in the nasal cavity. Though 
some regard a drainage-tube as unnecessary, it counteracts the tendency 
of the canal to close, and when of soft rubber is not at all irritating. 
These rubber tubes are one- quarter of an inch in diameter, from three- 
quarters of an inch to one and one-eighth inches in length, and three- 
sixteenths of an inch in caliber, with fl.anges at each end. With a wire the 
end of which has been bent to a right angle the distance through the al- 
veolus may be measured and a tube of proper length selected. The flange 
at the upper end of the tube is thinned by cutting away its upper surface 
until it may be squeezed into a gelatin capsule of proper size ; this is 
then oiled and readily passed through the opening into the antrum. A 
probe is then passed through the tube, the gelatin capsule forced off, the 




Lateral wall of nose. (Heymann.) «&, anterior 
end of middle turbinated body removed with 
scissors ; jjc, processus uncinatus, showing its re- 
moval with scissors. 



EMPYEMA OF THE MAXILLARY ANTRUM. 



371 



flange o]3ens out, and the tube is thoroughly secure. These tubes are 
inexpensive and very much more comfortable than gold. The patient 
should always stop up the opening with a pledget of cotton while eating. 
If mild irrigating solutions, such as suggested for washing the antrum 
through the natural opening, do not lessen the discharge, in washing 
from the oral orifice one can employ some of a more stimulating nature. 
These are zinc, copper in watery solution, and diluted hydrogen diox- 
ide. A solution of protargol of from five to twenty per cent, is often of 



Fig. 138. 




Lateral nasal wall after removal of middle turlDinal. (Heymann.) hpu, hypertrophic mucosa 
over processus uncinatus ; lihc, hypertrophied mucosa over bulla ethmoidalis ; sf, frontal sinus ; L Sch, 
Schiiffer's location for puncture of frontal sinus ; ss, chronic inflammation of sphenoidal sinus with 
thickened bony wall and cicatricial thickening of mucosa (m). 

great value, and a solution of potassium permanganate, one-quarter grain 
to the ounce, may be of advantage. It may take two years for the dis- 
charge to cease, and as in the interval the patient suffers only the discom- 
fort of having to wash out his antrum once or twice daily, it is well to 
wait before adopting the more radical measure of making a broad open- 
ing through the anterior wall of the antrum above the molar teeth. It 
is best to employ general anjBsthesia for this operation. The corner of 
the mouth should be drawn strongly upward by means of a broad, blunt 
hook, while an incision is made through the mucous membrane and 



372 



DISEASES OF THE NOSE AND NASOPHARYNX. 



Fig. 139. 




periosteum where the cheek joins the upper jaw, in a line above the promi- 
nences caused by the roots of the teeth, and extending from the canine to 
the second molar tooth. The mucous membrane should then be pushed 
upward and the bone exposed. If there be an empty space between two 
teeth or one can be created by the extraction of a 
root, or if there be a canal already drilled through 
the socket of a tooth into the antrum, the incision 
should be prolonged in this space to the free edge of 
the alveolar process. The antrum is then entered 
by means of a chisel one-half an inch wide, care 
being taken to keep well above the roots of the 
teeth, so as not to open the socket of a tooth. The 
opening is next enlarged upward and laterally by means of small bone 
rongeur forceps until the little finger can be passed into the antrum. 
This may be emj^loyed to search for foreign bodies, tumors, carious 
bone, projecting roots of carious teeth, displaced wisdom teeth, and 
other causes of chronic suppuration of the antrum. The cavity may 
also be inspected by means of the laryngeal reflector. Granulations are 
found only in the neighborhood of 



Ingals's drainage-tube 
for antrum. Full diame- 
ter; three different lengths. 



the canal that has been bored through 



Fig. 140. 



the alveolus or where there is carious 
bone, as the epithelial surface of the 
mucous membrane remains, as a rule, 
intact. The excrescences and oedem- 
atous folds of the mucous mem- 
brane should be scraped away with 
the sharp spoon, while septa can be 
broken down in the same way. The 
bleeding is severe. After curette- 
ment the cavity should be packed 
with iodoform gauze or gauze im- 
pregnated with iodol or bismuth. 
The packing must not be done 
tightly, lest it cause inflammatory 
reaction. "When the morbid process 
has had time to improve, after some 
days the antrum should be again in- 
spected and palpated, and any re- 
maining diseased tissues scraped 
away. This should be repeated from 
time to time until the cavity has 
ceased to discharge for some weeks, 
close. It is often difficult to keep it open, and the patient should be 
instructed to pass bougies into it to insure its patency. 

In the Caldwell-Luc operation the opening in the anterior wall of the 




Cysts and polypi in the antrum of Highmore. 
(Heymann, after Luschka.) 



It is then safe to let the opening 



EMPYEMA OF THE MAXILLARY ANTRUM. 373 

antrum, is immediately closed by sutures after the cavity has been curetted 
and treated with zinc chloride, while an opening is made into the lower 
meatus of the nose for further treatment. It does not seem advisable to 
exchange the ready access to the cavity of the antrum and the prolonged 
control of the processes there offered by the opening in the anterior wall 
for the difficult approach furnished by an orifice in the inferior meatus, 
even if this be made large bj' the resection of the lower turbinal, es- 
peciallj^ when one considers how obstinate suppurations of the maxillary 
sinus are, and how prone to return after apparently being cured. The 
chief advantage offered by the Caldwell-Luc operation is the freedom 
from danger of food entering the antrum. 

In cases of acute sinuitis of the maxillary sinus, if the symptoms be 
severe and lead the surgeon to suspect a collection of pus in the cavity, 
an opening may be made in the location mentioned by means of a trephine 
one-fourth of an inch in diameter, having a small drill in its centre as a 
guide. After the cavity is entered in this manner it should be washed out 
with a solution of protargol, from twenty to thirty grains to the ounce. 
The canal thus made should be allowed to close of its own accord, no 
drainage-tube being employed. 

The fourth method of opening the antrum is through the inferior 
meatus with resection of the inferior turbinal. The anterior half of the 
turbinal is removed with the scissors and snare, and an opening five- 
sixteenths of an inch in diameter made with the trephine or trocar. This 
can be enlarged still more if needed. Without the removal of the an- 
terior part of the turbinal the opening is very hard to find. This method 
is suited to those cases in which the teeth are perfect and the disease not 
of too obstinate a type. It does not drain as well as an opening through 
the alveolar process, as the floor of the antrum is generally lower than 
that of the nose. 

Tumors of the Antrum of Highmore. — The benign tumors originating in 
the antrum are mucous polypi, which are hyperi^lasias rather than true 
neoplasms, and papilloma, fibroma, angioma, and osteoma. All of these 
are extremely rare growths. Of these neoplasms the one of greatest im- 
portance is the osteoma, which may occur as a free growth unattached to 
the bony walls of the antrum. In this form it is generally solitary, very 
slowly increasing in size until it fills the cavity of the maxillary sinus, 
causing its distention until its walls form a thin bony shell. Ivory or 
spongy exostoses also occur, and the latter may be of sufficient size to 
crowd on the orbit and cause exophthalmos. 

The malignant tumors of the antrum are sarcomata and carcinomata. 
They are very rare, the former presenting as round- celled sarcoma, cysto- 
sarcoma, and fibrosarcoma. Early in their growth these tumors cause 
empyema of the antrum ; later they distend its walls, which may become 
so thin as to crackle under the pressure of the finger ; while at a still 
later period sarcoma perforates the antrum and extends to other tissues. 



374 DISEASES OF THE NOSE AND NASOPHARYNX. 

Carcinoma is generally found in the form of epithelioma, and many of 
these take their origin from the abnormal nests of epithelium occasionally 
found at the roots of the teeth. Those originating in other parts of the 
antrum are far more rare. The first symptom of carcinoma of the antrum 
is severe toothache that persists in spite of treatment or extraction of 
teeth. Neuralgias in the infraorbital nerve accompany that of the 
superior dental nerve. As the disease invades the alveolar process, hard 
palate, and anterior antral wall it causes protuberances and abscesses. 
Empyema of the antrum with very fetid discharge may occur earl3\ 
When the antrum is opened or as the growth perforates its walls the 
nature of the disease becomes apparent. The prognosis is absolutely bad, 
as the tumor always invades the tissues extensively before it is discov- 
ered. 

Symptoms of diagnostic importance are severe local neuralgias in the 
superior dental and infraorbital nerves, and anaesthesias when the growth 
has destroyed sensory nerve branches. Aspiration early in the disease 
is negative, while transillumination shows puj)il and cheek to be dark. 
A suspicion that a growth exists within the antrum is a warrant for an 
extensive opening in the anterior wall of the cavity for the purpose of 
exploration. 



CHAPTEE XIII. 

INFLAMMATION OF THE ACCESSORY SINUSES OF THE NOSE. 

INFLAMMATION OF THE FROXTAL SINUS. 
SjTaonyrae. — Sinuitis frontalis. 

The frontal sinus is in intimate relation with the foremost of the an- 
terior ethmoidal cells, which form neighboring chambers separated from 
it merely by thin bony walls ; therefore inflammation of the frontal sinus 
almost invariably involves some of the ethmoidal cells. 

Etiology. — The commonest cause of acute frontal sinuitis is acute 
coryza, of which it is a rather frequent accompaniment, especially in that 
form of acute rhinitis occurring with influenza. The acute infectious 
diseases may lead to inflammation of the frontal sinus. Injuries to the 
frontal sinus perforating its walls or causing subcutaneous fractures of 
them may cause the sinuitis, as also foreign bodies which find lodge- 
ment in the cavity. Bullets are especially j)rone to get into the frontal 
sinus and set up inflammation. 

Chronic inflammation of the frontal sinus is apt to result from the 
acute form, especially when the natural opening of the cavity is narrow 
or the upper part of the infundibulum contracted or encroached upon by 
a middle turbinal crowded over by a deflected septum or by some other 
cause. Inflammatory swelling or hyperj)lasia of the mucous membrane 
of the outlet of the frontal sinus or its neighborhood may cause obstruc- 
tion. Disease of the anterior ethmoidal cells, in addition to that of the 
frontal sinus, is apt to lead to obstructive hyperi)lasia and polj^poid 
growth of the mucous membrane in the infundibulum and middle meatus, 
causing a chronic blocking of the outlet of the frontal sinus. Simple and 
malignant growths in the sinus may cause its inflammation. 

PathoJogy. — Frontal sinuitis occurs in the acute and chronic forms. 
Acute inflammation is characterized hy inflammatory oedema of the 
mucous surface, at times extensive enough to fill the entire cavity of the 
frontal sinus. The accompanying hyperemia may lead to ecchymoses. 
The discharge is purulent or mucous, and has been found to contain the 
pneumococcus, staphylococcus pyogenes aureus, and diphtheria bacillus. 
The presence of the influenza bacillus has not been positively deter- 
mined. 

In chronic inflammation the mucous membrane in the more recent 
cases is swollen and hypertrophied, either smooth or displaying j)oly]3oid 
swellings and irregularities, or even polypi. The color of the mucous 
surface varies from pale pink to red. The epithelial covering is generally 

375 



376 DISEASES OF THE NOSE AND NASOPHARYNX. 

found intact. Later in the disease the mucous membrane becomes more 
dense and fibrous. 

Symjytoms. — The most marked symptom of sinuitis frontalis is pain, 
which varies from a sense of weight in the region of the sinus to an in- 
tense aching, radiating to the eye and other portions of the head. The 
sensations are of a throbbing nature, and the pain is increased by bend- 
ing forward, coughing, sneezing, or by anything causing the veins to 
distend. 

When the outlet of the sinus is stopped up, absorption of the air in 
its cavity takes place with the production of negative pressure, or the 
secretions accumulate until they produce hydrostatic pressure on the 
mucous surface. Both of these conditions are probable causes of the 
pain, which is often much relieved by anything freeing the way to the 
sinus. The pain is apt to be periodic and worse in the morning, gradu- 
ally improving during the day, as sneezing, posture, and blowing the 
nose tend to free the outlet of the cavity and enable it to discharge its 
contents. 

The pain may be mistaken for that caused by supra- orbital neural- 
gia, and is apt to appear at nine or ten o'clock in the morning. Other 
symi^toms are dizziness, heaviness, dulness of mind, and moderate fever. 
Ocular symx^toms may occur, such as photophobia and lachrymation. 
(Edema of the uj^per lid and forehead appears in rare instances. The 
disease lasts a week or two, and may end suddenly with free discharge 
and great relief. Some cases become chronic, others show a decidedly 
septic tendency, the supx^uration extending by continuity or perforation 
to neighboring regions. The carriers of the infection are often septic 
thrombi in the veins perforating the bone. An abscess may thus form 
in the orbit at its upper inner angle, displacing the eye, or abscesses may 
appear on the anterior surface of the sinus, or in grave cases suppuration 
may penetrate its posterior wall, causing subdural abscess, abscess in the 
frontal lobe of the cerebrum, meningitis, and pysemic thrombosis of the 
longitudinal sinus. 

In chronic frontal sinuitis the pain is much like that in the acute form, 
but is seldom as severe, and, instead of lasting but a few days, exists 
with varying intensity for months or years. Some patients have pain 
only during acute colds in the head. In the milder cases there is merely 
a feeling of weight in the region of the sinus, in others there is more or 
less severe headache, located in the frontal region and, as in acute sinu- 
itis, worse in the morning. Physical exertion, eating, and the use of 
alcohol add to the pain. The patient is disinclined to physical or mental 
work, and depression of mind may exist even to the extent of melancholy. 
There is inability to concentrate the thoughts or to comprehend readily. 
Some patients are extremely nervous, others weak, depressed, and neu- 
rasthenic. Functional ocular disturbances may be present : i^hotophobia, 
the ai)pearance of a mist before the eyes, diminished acuteness of vision, 



INFLAMMATION OF THE ACCESSORY SINUSES OF THE NOSE. 377 

and lessening of the visual field. The pus flows from the frontal sinus 
into the infundibulum and appears in the middle meatus together with 
that from the anterior ethmoidal cells, if these be also diseased, as they 
generally are. The amount of discharge is less than in disease of the 
antrum, and is usually not fetid. 

Dilatation of the frontal sinus is probably the result of its distention 
by retained secretions following chronic obstruction of its outlet. The 
dilatation may become apparent from two to twenty-five years after the 
beginning of the sinuitis, and the character of the retained secretions 
may be serous, mucous, purulent, or mucopurulent. The orbital, cere- 
bral, and frontal walls of the sinus seldom protrude equally ; usualh' one 
yields to the pressure sooner than the others, until the bone becomes so 
thin that it crackles under the finger and in some places disappears 
entirely', permitting the mucous lining of the sinus to be forced through 
it like the sac of a hernia. In this manner the inner wall encroaches on 
the cranial cavitj', making pressure on the frontal lobe, — a condition 
which, however, causes no cerebral symptoms. Protrusion of the orbital 
wall dislocates the eye downwaid and outward, limiting its motions and 
in rare cases producing diminution or loss of vision. Protrusion of the 
anterior wall of the sinus usually accompanies that of the orbital wall ; 
the latter, being thinnest, yields first. The size of the distended sinus 
may reach that of a pigeon's egg and in rare cases has attained the 
dimensions of a fist. Dilatation of the frontal sinus as the result of 
chronic inflammation is rare. 

Chronic frontal sinuitis is liable at some time during its course, per- 
haps after years, to result in ulceration of the mucous membrane with 
consecutive periostitis and necrosis. This is generally the result of some 
acute exacerbation of the disease. Either as a consequence of the 
necrosis or by way of the perforating veins of the bone the suppurative 
process may extend beyond the sinus. In this manner abscesses may 
form on the forehead over the sinus, leading at times to fistulge that 
penetrate its cavity. 

^Yhen the process extends through the orbital wall, in most cases the 
result is the formation of a localized abscess that bursts through the 
upper lid, producing a fistula. In severer cases the eyeball is dislo- 
cated downward and outward by the swelling, its motions and those of 
the upper lid limited, while vision may be diminished or lost. In the 
worst cases there are phlegmonous inflammation of the entire orbit, 
thrombosis of the oj^hthalmic vein and consecutive thrombosis of the 
cavernous and petrosal sinuses, and pyaemia. The entire upper and 
inner wall of the orbit may become necrotic. In cases in which the 
septic process penetrates the posterior or cerebral wall of the sinus 
there may be subdural abscesses, meningitis, abscess of the frontal lobe, 
thrombosis of the longitudinal sinus, and pyaemia. Those forms of 
chronic sinuitis which tend to abscess formation are characterized by 



378 



DISEASES OF THE NOSE AND NASOPHARYNX. 



intensity of pain and fetor of discharge. These symptoms may extend 
over long periods of time before the sui)i3uration involves regions beyond 
the sinus. 

Diagnosis. — The most characteristic symptoms of inflammation of the 
frontal sinus are pain localized in the region of the cavity and tenderness 
on pressure over its anterior and orbital walls. The various methods of 
intranasal examination may lead to a diagnosis. The middle turbinal 
can be sprung aside towards the septum by means of Killian's long, 
narrow bivalve sj)eculum for rhinoscopy of the middle meatus ; this 
may enable one to see the discharge as it flows from the sinus beneath the 
anterior end of the middle turbinal. Cocaine must be applied previous 
to this examination. In acute sinuitis probing or irrigation of the sensi- 
tive parts is best omitted, but in chronic disease attempts can be made to 

Fig. 141. 




Probing the frontal sinus. (Heymann, after Lichtwitz. 



probe the sinus through its natural opening. This is possible for experts 
in about fifty per cent, of the cases. When the sinus opens underneath 
the anterior end of the middle turbinal in front of the processus uncina- 
tus and hiatus semilunaris, the passing of a probe into the sinus may 
be surprisingly easy ; when it opens into the upper part of the hiatus 
semilunaris it may be impossible to probe the sinus. If the frontal 
sinus opened by a simple foramen, it would be very easy of entrance, 
but as access to it is gained by means of a canal that is generally five- 
eighths of an inch in length and may be tortuous, it is often a hard 
matter to probe it. 

Ko exact curve can be suggested for the probe, as it must be bent to 
suit the case. As a general rule, however, a probe with a curve three 



INFLAMMATION OF THE ACCESSORY SINUSES OF THE NOSE. 379 

inches iu length, having a depth or radius of one and three-sixteenths 
inches, is the best to begin with. In some cases it is well to bend the 
end of the probe at a right angle to its shaft and give the extremity a 
length of three-quarters of an inch. The canal of the outlet of the 
sinus must be entered from behind, as its normal direction is downward 
and backward. The probe should be gently inserted as high up as pos- 
sible underneath the anterior end of the middle turbinal before its handle 
is lowered to give its extremity the necessary direction upward and for- 
ward. It is difficult to tell to what length the probe has entered, and 
whether it is in the sinus or detained in its outlet. For this reason Kil- 
lian uses a second probe which has exactly the curve of the one passed 
into the sinus. This he places against the face in a position correspond- 
ing to that assumed by the probe in the naris, and estimates the depth 
to which the first probe has entered the sinus by means of the one held 
externally. If the probe enter two and one-half inches, as measured 
from the nasal entrance, it is probably in the sinus. Eemoval of the 
anterior end of the middle turbinal in the manner mentioned iu the 
previous article (page 369) will greatly facilitate probing, but even here 
anatomical conditions may prevent it. 

Probing may be followed by irrigation or insufflation of the sinus to 
wash or blow out the secretions as an aid to diagnosis, and for this pur- 
pose a fine tube of the same curve as the probe is introduced. AVhen 
the sinuses communicate, discharge can be made to appear in the other 
side of the nose by irrigation or insufflation. For diagnostic jniri^oses a 
trocar or Palmer's frontal sinus drill may be i^assed under the middle 
turbinal and made to enter the sinus, or the trocar may be forced into 
the sinus by passing it between the septum and middle turbinal and 
piercing the latter at its base. The x)roceeding is, however, not without 
danger, and some advise against it, as there is risk of piercing the 
cranial cavity through the posterior wall of the sinus. Transillumina- 
tion is used for diagnostic pur^^oses, but the results are very uncertain. 
A rubber cylinder with an ai^erture one-half of an inch in width is 
slipped over the light and pressed firmly against the upper inner wall 
of the orbit just behind its free border. Under these conditions thicken- 
ing of the mucous membrane or pus in the sinus may cause a shadow. 
Ocular disturbances are to be carefully searched for. 

If it be impossible to arrive at a diagnosis by intranasal methods, the 
sinus maj" be opened fi-om in front b}" a small incision in the eyebrow and 
by drilling through the anterior wall with the dental engine. An aspi- 
rating needle may be passed through the opening and secretion withdrawn, 
or fluid injected and withdrawn for diagnostic purposes. 

Prognosis. — Most cases of acute sinuitis recover, a small number be- 
come chronic, and in very rare instances the septic process extends 
beyond the sinus, causing serious complications. Chronic inflammation 
of the frontal sinus probably does not spontaneously recover. Eemoval 



380 DISEASES OF THE NOSE AND NASOPHARYNX. 

of obstructions to the outlet of the canal will often suffice to stop the 
headache and ocular disturbances, so that the patient is satisfied, even 
if the sinus continue to discharge moderately. Operative interference 
may bring about recovery in the more severe cases, but often this has 
to be of a most radical nature. When the suppuration extends to the 
cranial cavity the result is usually fatal. 

Treatment. — Acute catarrh of the frontal sinus as ordinarily seen yields 
to the measures employed for the acute coryza causing it. The septic 
form, causing abscess of the orbit, requires the opening of the sinus from 
the front. When there ^re intracranial sup^Durations, radical oiDcrations 
involving the opening of the cranial cavity are required ; these belong 
properly to general surgery. 

In the treatment of chronic inflammation of the frontal sinus the first 
aim must be to free the outlet in the nose from obstructing hypertrophies 
or polypi. If the sinus be readily accessible, irrigation may bring about 
recovery. For this purpose a saturated solution of boric acid or normal 
salt solution is a useful fluid. In most cases it is necessary to remove 
the anterior part of the middle turbinal and the processus uncinatus 

Fig. 142. 





Palmer's frontal sinus drill. 



in the manner described in the preceding article. This gives better 
access to the opening of the sinus, which may be enlarged with the Griin- 
wald-Hartmann forceps with upturned cutting beak, or the sinus may 
be entered with the Palmer drill in the manner described above. When 
there is decided distention of the sinus, making its entrance easy, a 
trocar resembling Krause's antrum trocar may be employed, through 
which a drainage-tube may be passed into the frontal sinus. To intro- 
duce the drainage-tube here recommended in such a case, fhe tube, fun- 
nel end uppermost, should be passed over the end of a copper wire, 
slightly roughened to prevent slipping. The tube should then be tied 
fast to the wire near the end by a strong silk thread in a bow-knot that 
can easily be untied by pulling on the long ends of the thread which 
hang from the nostril. With a cambric needle a strong silk thread is 
passed through the flange at the opposite end of the tube, close to the 
opening, so that it cannot tear out. This thread should be about two feet 
long, and both ends will hang out of the nose when the tube is introduced. 
The tube, now being well soaped so that it will slip easily, is pushed by 
the wire to which it is tied through the canula into the frontal sinus 



INFLAMMATION OF THE ACCESSORY SINUSES OF THE NOSE. 381 



and the canula then withdrawn. The ends of the thread that ties the 
rubber tube to the copper wire are then pulled upon and the thread 
brought away. The copper wire is next withdrawn, leaving the rubber 
tube projecting into the frontal sinus, with the thread attached to its 
lower end. Lastly-, with a good illumination of the nasal cavity, this 
thread is steadily pulled and the tube drawn down until the flange just 
escapes from the opening left by the trocar into the upper part of the 
nasal cavity. One end of the thread is now cut and. with a probe pressed 
against the end of the rubber tube to keep it from slipping, the thread is 
withdrawn, leaving the drainage-tube in position. When, because of ana- 
tomical dif&culties, the sinus cannot be entered from the nose, or when 
there is already a fistula in the orbit or on the forehead, or when fetid 
discharge indicates ulceration and necrosis of bone, the sinus should be 
opened from without. This should also be done 
in septic cases with abscess formation about the Fig. 143. 

sinus and in cases with dilatation of the sinus. 
The incision should be made within the eye- 
brow along its lower border, and extend from 
its middle to the centre of the nasal bridge and 
across, if needed. The lower flap should be 
pushed down, exi^osing the edge of the orbit, 
while the up]3er border is pushed up with the 
periosteum. The sinus should then be oxDcned 
near the angle of the orbit with drill, trephine, 
trocar, or chisel. The oj)ening should be large 
enough to admit the end of the little finger for 
thorough exploration. The cavity should be 
cleaned out and curetted, if necessary. If pus 
exist in the opposite sinus, the septum must be 

broken down so as to allow free drainage. The sinus should then be 
thoroughly irrigated with a bichloride or other antiseptic solution, and 
communication with the nose re-established. This may be done by 
pushing a trocar through the frontonasal canal into the nasal cavity, 
guided by the little finger, which has been introduced into the nostril of 
the corresponding side. Krause's antrum trocar is well adapted for 
this purpose, A slightly funnel-shaped rubber tube is then passed 
through this opening from the frontal sinus to the nasal cavity, where it 
is allowed to remain until suppuration has ceased ; the tube may then 
be withdrawn through the uaris. In this oj^eration the external wound 
may sometimes be closed at once, or it may be packed with iodoform 
gauze and kept open for a time, if necessary. The cavity must be washed 
from time to time and in some cases daily until suppuration ceases, 
which may be expected in from one to six months. The incision within 
the eyebrow will leave a scar that is hardly visible when it has been 
possible to secure prompt healing of the external wound. Finally, as 




Ingals's frontal sinus drain- 
age-tube. A, section of tube 
showing thinness of rubber at 
funnel, allowing it to be easily 
pulled out ; B, showing flange at 
bottom to prevent escape of tube 
into frontal sinus. 



382 DISEASES OF THE NOSE AND NASOPHARYNX. 

recovery takes place the drainage-tube is removed through the nose. 
The chief danger, especially when the oi)ening in the frontal bone has 
been made too small, is that the posterior wall of the sinus may be 
perforated by the trocar when the attempt is made to re-establish the 
opening to the nose, and in one case death has resulted from this acci- 
dent. Ocular disturbances have also been reported after the operation. 

There are many varieties of the operation. Removal of the anterior 
wall of the sinus, if extensive, is followed by sinking in of the skin 
and a disfiguring depression. To avoid this osteoplastic resection of the 
anterior wall of the sinus, including the rim of the orbit as far as the 
sinus extends, is performed, the bone flap turned up, and the interior of 
the sinus thus made very accessible. 

When the extent of the disease requires it, Killian opens the sinus 
widely from in front, leaving the rim of the orbit, which can be accu- 
rately severed from the bone, to be removed by means of a circular saw 
driven by the dental engine. He then removes the orbital floor of the 
sinus from below and above with chisels and forceps, and, after curette- 
ment, continues the incision on the dorsum of the nose as far as the 
nasal bones extend, and, dividing these with a chisel and the nasal 
process of the superior maxillary with a saw, he turns this and the nasal 
bone outward as a flap. In this way he obtains direct access to the out- 
let of the sinus and diseased ethmoidal cells, which latter he removes, 
thus creating a broad opening between the sinus and the nose which 
is in no danger of closing by granulation, as openings made by the 
trocar are apt to do. The flaps are replaced at once, the cavity tam- 
poned with iodoform gauze, and the wounds either sutured immediately 
or after two days. Other diseases of the frontal sinus come more prop- 
erly within the domain of general surgery. 



EMPYEMA OF THE SPHENOIDAL SINUSES. 

The sphenoidal sinus is a large cavity extending from a point about 
one- quarter of an inch back of the vomer in the nasopharynx forward 
to the cribriform plate of the ethmoid bone, so that a portion of its 
lateral wall forms the inner wall of the orbit at its deepest part just 
posterior to the body of the ethmoid bone. The sinus is divided by a 
septum into two cavities, often very unequal in size. The opening of 
each sinus is in the anterior wall, generally at its upper part. The open- 
ing in the bone is larger than that in the mucous membrane, the latter 
usually being of sufficient size to admit a stout probe. 

Etiology. — Acute inflammation of the sphenoidal sinus is usually 
the result of acute infectious rhinitis. The deep seat of the cavity pro- 
tects it from anything but extraordinary traumatic influences. Foreign 
bodies — in one instance a piece of straw — have been found in the sinus, 
and have excited inflammation. Chronic rhinitis, especially if purulent, 



INFLAMMATION OF THE ACCESSORY SINUSES OF THE NOSE. 383 

predisposes to sphenoidal sinuitis ; it may also be an accompaniment of 
atrophic rhinitis, and in some cases doubtless precedes and causes it. 
Discharge from an inflamed frontal sinus may flow backward during 
sleep and infect the sphenoidal sinus, or this may become diseased sec- 
ondarily as a result of inflammation of the ethmoidal cells, the infection 
spreading through their walls by continuity, perforation, or because the 
discharge enters the sphenoidal sinus. 

Chronic inflammation of the sphenoidal sinus results from the acute 
disease. This is especially liable to be the case in scrofulous or syphi- 
litic subjects, or x^eople in whom nasal mucous polyi)i block the entrance 
to the sinus, or when chronic rhinitis lowers the recuperative powers of 
the nasal structures. 

Pathology. — The changes due to acute or chronic inflammation of the 
mucous lining of the sinus are the same as those found in disease of the 
antrum or frontal sinus, and have been described with those affections. 
Polypi have been found in the cavity of the sphenoidal sinus, and in 
chronic cases the bone maj' become carious or necrotic. 

Sijmjytoms. — As in inflammation of the other sinuses, pain is the most 
marked sym^^tom of the disease in both the acute and chronic forms. In 
the acute variety there is generally a history of a severe cold accompanied 
by an almost unendurable pain in the forehead, occiput, and deep in the 
skull. A feeling of pressure from behind is felt in one or both eyes, ac- 
companied b}' dizziness. The x^ain is due to pressure on the sensitive 
nerves of the sinus on account of the swollen mucosa and retained secre- 
tion, and lasts much longer than that accomj)anying a common cold, which 
it also greatly exceeds in severity. Inspection shows great swelling of 
the deeply reddened mucous membrane between the middle turbinal and 
septum, so that the olfactory region is closed, the mucous surfaces being in 
contact. The mucous covering of the anterior wall of the sinus is also 
swollen and protrudes, while the orifice is often closed by the swelling. 
In acute sinuitis the discharge is slight and usually mucopurulent. It 
appears in the region of the tuberculum septi, or exuding from the olfac- 
tory fissure between the middle turbinal and the septum, or flowing back 
into the nasopharynx. 

In chronic inflammation of the sinus the j^atieut comi)lains of the 
abundant discharge, which appears in the form of crusts or idus in the nose 
or nasoj)harynx, whence he hawks the secretion with difiScultj'. He may 
notice that the discharge has a foul odor, though this may not be ap- 
preciated by others. Anosmia and disturbance of taste occur, these 
symptoms being due to the closure of the olfactory region. Dizziness, 
supra-orbital neuralgia, pain in the centre of the head, and stiffness 
of the nape of the neck are i)rominent symptoms. They are often inter- 
mittent, and when severe may lead to nausea and vomiting. The pain is 
usually in the same region. As in disease of the other sinuses, marked 
cerebral symptoms accompanj^ the ailment, — viz., hebetude, forgetfulness, 



384 DISEASES OF THE NOSE AND NASOPHARYNX. 

and depression amounting to melanclioly. The pain, the chronicity of 
the affection, and the annoyance of the often fetid discharge discourage 
the patients greatly. They look miserable and cachectic, and functional 
eye disorders occur. 

When nasal mucous i)olypi and hypertrophic rhinitis accompany the 
disease they interfere with the patient's breathing, while the crusts help 
to block the nares. Inspection shows the root of the nose in some cases 
to be slightly swollen and broader than normal. The nasal interior pre- 
sents the changes due to chronic rhinitis, while the tuberculum septi, 
which is the normal thickening of the mucous membrane of the septum 
opposite the anterior end of the middle turbinal, and the middle turbinal 
itself are hyper]3lastic and generally hidden by a crust, underneath which 
is a ls.jer of fluid pus. Pus can be seen exuding from the olfactory re- 
gion between the middle turbinal and the septum. Insi)ection of the 

Fig. 144. 




Probe passed into sphenoidal sinus through the natural opening. (Lichtwitz.) 

nasopharynx shows thin crusts adherent to the vault of the pharynx, the 
septum, and the choana on the side of the diseased sinus. Fluid pus can 
also be seen running down the lateral wall of the choanse. 

Diagnosis. — In order to reach a diagnosis in acute sinuitis it is necessary 
to make the sinus accessible, and for this purpose in many cases the sur- 
greon must remove the anterior end or all of the middle turbinal in the 
manner described in the diagnosis of empyema of the antrum. In other 
cases it is possible to x)ass a probe into the sinus without this preliminary 
operation. The probe used should be stout and stiff, three-thirty-seconds 
of an inch in thickness, and bent nearly at a right angle to its handle to 
avoid having the hand holding it interfere with vision. If the probe be 
passed from the lower border of the nostril upward and backward across 
the centre of the middle turbinal parallel to the septum, it will reach the 
anterior wall of the sinus. When this is softened by disease, the probe 



INFLAMMATION OF THE ACCESSORY SINUSES OF THE NOSE. 385 

will readily enter the sinus by its normal entrance or by perforating the 
mucous membrane and softened bone. The probe may suddenly slip 
through the oi:)ening. or the thin plate of bone may be felt to give way 
as it is punctured. After the probe has entered, the patient should be 
told to press the opposite nostril shut and blow forcibly through the one 
on the side of the diseased sinus, when i^us and blood will be aspirated 
by the blast into the naris. This generally gives him immediate relief, 
— a matter of diagnostic value. In making the diagnosis of chronic sinu- 
itis the examiner must go through the same procedures, being careful to 
exclude or recognize coexisting disease of other sinuses. Carious bone 
will give its characteristic grating sensation to the probe. 

Prognosis. — Many cases of acute sinuitis recover spontaneously, but 
have a tendency to recurrence, and some become chronic. 

Chronic inflammation shows no tendencj^ to s^^ontaneous recovery. It 
seldom threatens life, but serious complications, though rare, may occur. 
Caries and necrosis of the bodj" of the sphenoid, or spreading of the 
septic inflammation through the bone, may cause a deep-seated orbital 
suppuration with optic neuritis, blindness, and later fatal meningitis. 
Fatal hemorrhage due to perforation into the cavernous sinus, sinus 

Fig. 145. 



Spoon-shaped probe of Max Schiiffer for entrance into sphenoidal sinus. 

thrombosis with thrombosis of the ophthalmic vein, destruction of the 
sphenopalatine ganglion, and brain-abscess are among the possible oc- 
currences. 

Treabnent. — The treatment of acute and chronic empyema of the 
sphenoidal sinus is essentially the same, the most important object being 
free oi)ening of the cavity for drainage. As a preliminary it may be 
necessary to cut away the anterior i3art or all of the middle turbinal, 
and hyi^ertrophies or polypi must l)e removed. Mere probing of the 
sinus does not insure a sufficient opening, so that the probe should be 
immediately followed by a small, sharp spoon, with which the anterior 
wall must he broken down in a downward direction as far towards the 
floor of the sinus as possible. One of the larger Griinwald sharp spoons 
is an instrument well suited for this purpose. The loose fragments of 
bone and such j)ortions of the lower j)art of the anterior wall as are too 
thick to yield to the curette should then be cut away with nasal bone- 
forceps to the floor of the sinus. The floor of the cavity can also be 
entered from below by way of the nasopharynx with Ingals's diamond 
drill trephine driven by the dental engine ; the trephine is attached to 
the engine by means of a right-angle attachment for the chuck. The 
cavity can be penetrated from in front by a trocar or long trephine. 

25 



386 



DISEASES OF THE NOSE AND NASOPHARYNX. 



Artificial openings into the sinus show a strong tendency to contract 
rapidly, and therefore should be made as large as possible. 

These proceedings give drainage at the lowest point, and may be 
followed by irrigations and insufflations of iodoform powder. Hemor- 
rhage is sometimes severe, but can usually be checked by irrigation with 
a one per cent, solution of citric acid. When the bleeding stops it is 
well to treat the interior of the sinus with a fifty to eighty per cent, 
solution of trichloracetic acid, applied with a swab ; this cauterizes dis- 
eased mucous surfaces and reaches places that cannot be scraped with 
the curette. The anatomical location of the sphenoidal sinus prevents the 
sharp spoon from reaching more than a limited part of its area. Necrotic 
or carious bone is generally situated near the outlet, and can, therefore, 
be removed with the curette or taken away with nasal bone- forceps. 

Fig. 146. 




Bone-forceps of Max Schaffer for opening the sphenoidal sinus 



After completion of the operation, iodoform or iodol gauze should be 
packed against the sinus to stop bleeding or to prevent its recurrence. 
The plug should be left in place for two days. 

Carious or inflamed bone is exquisitely sensitive, and when this is 
removed thorough and repeated applications of cocaine are needed. After 
the operation the patient often has prompt relief from pain and head- 
ache 5 in other cases this comes gradually. The mental symptoms also 
disappear together with the swelling of the bridge of the nose. If the 
operation be thoroughly done at the first sitting, it is seldom necessary 
to do anything further. It is well, however, to keep the nasal cavity 
clean by means of sprays or irrigations. 



SUPPURATIVE ETHMOIDITIS. 

The ethmoidal cells form a connecting chain in the continuous row of 
air-cells that extends from the frontal to the sphenoidal sinus. Their 
outer covering, the lamina papyracea, forms a large part of the inner 
wall of the orbit. They x)roject into the nose in its upper portion on 
each side of the septum, while the upper and middle turbinals jut down- 



INFLAMMATION OF THE ACCESSORY SINUSES OF THE NOSE. 387 

ward from their lower surface. The bone covering the ethmoidal cells 
and forming the partitions separating them from one another and from 
the frontal, sphenoidal, and maxillary sinuses is of shell-like frailty. An 
ethmoidal cell, at times of large size, is found in the anterior part of the 
middle turbinal. 

Etiology. — Ethmoiditis is in many instances secondary to sinus disease 
elsewhere. Sinuitis af the frontal sinus can hardly exist without in- 
volving the anterior ethmoidal cells. Suppuration of the antrum may 
extend to the ethmoidal cells through the thin bone of this cavitj^ either 
by caries and perforation or by continuity of inflammation through the 
bone or its venous orifices. In a similar way disease of the si^henoidal 
sinuses may pass through the thin lamina of bone separating them from 
the posterior ethmoidal cells. Pus from sui^inirating sinuses may enter 
the ethmoidal cells through their orifices and infect them in this manner. 
The other causes of ethmoiditis are the same as those of inflammation 
of the sphenoidal sinus. 

Fatliology. — The thin bone forming the wall of an ethmoidal cell is 
softened and inflamed as a result of the suppurative j)rocess, as is the 
case with the plates of bone forming the outlets of the frontal and 
sphenoidal sinuses. This condition makes entrance to a diseased cell or 
sinus easier than to a normal one. The mucous lining of the ethmoidal 
cells undergoes the changes usual to sinus disease and described in the 
preceding articles. The large area of their lining, together with their 
imx^erfect drainage, gives a reason for the great amount of pus that in 
many cases flows from their interior. Proper drainage soon cuts short 
the suppuration. 

Symptoms. — The pain caused by suppuration of the ethmoidal cells is 
perhaps more intense than that due to disease of the other sinuses ; it is 
not sufficiently characteristic, however, to distinguish it from pain origi- 
nating in these other cavities. It is felt at the root of the nose, the 
lower inner part of the orbit, the upper i^art of the cheek, and the region 
of the frontal sinus. The pain m^j be intermittent in character and last 
for some time before there is a discharge of pus from the nostril. 

i!^asal respiration becomes blocked and the swollen middle turbinal 
interferes with the sense of smell, the mental symptoms are like those of 
disease of the other sinuses, and the secretion of pus may be scanty or 
very abundant. Pressure on the lachrymal bone or on the root of the nose 
may intensify or bring on the pain, and insi)ection at times shows oedema 
of the root of the nose, the infraorbital region, or the cheek. The bridge 
of the nose may seem abnormally wide, and in some cases, when the cells 
of the ethmoid labyrinth are distended, they bulge into the orbit, causing 
swelling at the inner canthus, with displacement of the globe outward 
and diplopia. This may be the first symptom that brings the patient to 
the surgeon. \Yhen the anterior ethmoidal cells are involved, pus will 
appear in the middle meatus, coming from the hiatus semilunaris j when 



388 DISEASES OF THE NOSE AND NASOPHARYNX. 

the posterior cells are diseased the pus appears in the olfactory region, 
between the middle turbinal and septum, and also flows back over the 
body of the sphenoid into the nasopharynx, appearing on its vault and 
in the choana in the form of tough flakes or crusts. 

The intimate relation of the middle turbinal to the ethmoidal cells, 
jutting as it does from the bony covering of their lower portion, causes 
it to sufier greater pathological changes than occur in disease of the 
other sinuses. If one or more of the ethmoidal cells enter its base they 
distend within the turbinal, at times greatly expanding it. Its mucous 
surface is often covered with j^olypoid excrescences, and the turbinated 
bone itself becomes softened and inflamed. Pus may exude from its base, 
and may be seen to ooze from all sides of it when it is moved with a 
probe. The pus is often fetid, but seldom markedly so. In some cases 
the objective signs are insignificant and the discharge of pus slight. 

Diagnosis. — In those cases in which the discharge is profuse and the 
disease pronounced the diagnosis presents less difiiculty than in those 
in which the objective signs are but slightly marked, the discharge insig- 
. nificant, and the affection limited to one or two cells. 

As in disease of the other sinuses, the probe is the most important 
of diagnostic aids. It should be bent according to the anatomical con- 
ditions present, but a probe with its extremity bent at an obtuse angle is 
the most generally useful. In the search for disease of the posterior 
ethmoidal cells the probe should be passed up in the olfactory region 
between the middle turbinal and septum ; the anterior cells may be 
reached by inserting the probe into the middle meatus, and passing it 
underneath the middle turbinal back to the hiatus semilunaris. If, in the 
search for the posterior cells, the probe be passed up directly along the 
septum it will miss them and touch the cribriform plate, and therefore it 
should be kept close to the middle turbinal, while the extremity of the 
probe is directed outward at an angle of about forty-five degrees. The 
cells are to be found at the posterior end of the middle turbinated body, 
and hence the probe must be passed sufficiently far back to reach them. 
As in empyema of the other sinuses, the middle turbinal is the structure 
most in the way of the probe or other instruments, and may need re- 
moval at its anterior extremity or for its whole length before it is pos- 
sible to diagnose or treat disease of the hidden ethmoidal cells. In 
probing them it is generally necessary to break through their bony 
walls ; the probe, therefore, should be of stiff material and three-thirty- 
seconds of an inch thick. It is not well to be too hasty in the diag- 
nosis of caries of the bone, as the rough edges of the fractures left in 
pushing a way into the cell may be taken for dead bone. The probe 
passes readily through the bone where it is softened by inflammation, 
while sound bone will offer a good deal of resistance. Probing a diseased 
cell may elicit the characteristic pain felt spontaneously by the patient at 
other times. 



INFLAMMATION OF THE ACCESSORY SINUSES OF THE NOSE. 389 

Progyiosis. — The great number of cells forming the ethmoidal laby- 
rinth causing hidden foci of suppuration that are badly drained, if 
drained at all, and the dangerous region they occuj^y making vigorous 
operative interference risky, render the prognosis as to rapid recovery less 
favorable than in disease of the sphenoidal sinus. The disease may ex- 
tend over many years, and in some patients nothing more than improve- 
ment of the condition may be expected. Grave complications are rare, 
though orbital abscess, with the serious consequences mentioned as re- 
sulting from sphenoidal or frontal empyema, meningitis, abscess of the 
brain, and emphysema of the cellular tissue of the orbit, may occur. Ne- 
crosis of large parts of the body of tlie ethmoid or of its cribriform plate, 
hemorrhages, and cerebral suppurations are usually results of the disease 
when caused by syphilis. 

Treatment. — The introduction of the probe can immediately be fol- 
lowed by that of the sharp spoon. This should take the same direction as 
the probe. To reach the anterior cells it must be passed ux)ward and 
backward between the middle turbinal and outer nasal wall, and to reach 
the posterior cells, upward and backward along the inner surface of the 
middle turbinal and also behind this bone. It may be necessary to re- 
move the middle turbinal wholly or in part in order to make the eth- 
moidal cells accessible. If the entire middle turbinal is to be removed, 
this is best done with strong nasal bone- force j)S ; Pynchon's forceps are 
well suited to this purpose. Dead and carious bone may be scraped 
away with the curette, and bony septa between the cells maj^ be broken 
down with it or perforated with the drill or trephine, or cut away with 
bone-forceps. In the same manner polypoid and fungous masses may be 
removed. The sharx3 spoon or forceps finds less resistance from the in- 
flamed and softened bone of the diseased portions than from the firm 
bone of the healthy parts, so that in a measure the sense of touch indi- 
cates to the surgeon how far to go. It should never be forgotten that in- 
struments too vigorously used may penetrate the orbit or the cranial 
cavity. After all the diseased cells have been opened in this manner by 
breaking down their bony walls, the honeycomb-like ethmoidal labyrinth 
is transformed into a large irregular cavity the recesses of which can be 
felt rather than seen. The hemorrhage is often severe, and the operation 
may have to be interrupted to check it by temporary tamponing. When 
as much as possible of the diseased tissue has been removed, the interior 
of the cavity should be cauterized with an eighty per cent, solution of 
trichloracetic acid, insufflated with iodol, and tamponed with iodol or 
bismuth lint, which should be removed after two days. Some favorable 
cases recover as a result of the first oi)eration, but manj^ drag on for 
months or years, improved but not well. Secondary operations are often 
needed, as some cells may have escaped opening at the first or subse- 
quent interferences. Eecurrences of the suppuration may take place 
as the disease lights up in cells not involved at first. If disease of the 



390 DISEASES OF THE NOSE AND NASOPHARYNX. 

antrum exist, it must be remedied before one can hope to cure that of the 
ethmoidal cells. 

For after-treatment most satisfactory results may be obtained from 
injecting into the ethmoidal cells^ with a long, slender silver canula 
attached to a hypodermic syringe, fifty per cent, solutions of hydrogen 
dioxide or five per cent, protargol, and subsequently oily solutions con- 
taining oil of gaultheria one minim, oil of caryophyllum five minims, 
terebene ten minims, to one ounce of oleum petrolatum album, the 
strength being slightly increased or diminished according to the effect. 
They should not cause pain for more than half an hour afterwards. At 
the same time the nasal cavity should be washed two or three times daily 
with a detergent solution, and a similar oily preparation, or one somewhat 
weaker, may be used as a spray by the patient morning and evening. A 
powder containing five per cent, of aristol, two per cent, of cocaine, 
twenty per cent, of boric acid, and forty per cent, of iodol, with sugar of 
milk for an excipient, ma.y advantageously be used by the pg,tient once 
or twice daily as an insufflation. 



CHAPTEE XIV. 

DISEASES OF THE XASAL SEPTUM. 
DEFLECTION OF THE NASAL SEPTUM. 

Almost all nasal septa bulge slightly into one or the other nostril, 
and a deflection becomes pathological only when it obstructs respiration. 
Deflection of the septum is far more common among Europeans than 
other races of men. Septal deflection among negroes is said to be 
infrequent, and even the American Indian, with his aquiline nose, is 
not subject to it. The proi^ortion of men to women with the deformity 
is about two-thirds for men and one-third for women. Sei)tal deflec- 
tions can be found at any age, and even new-born infants may present 
them. They are not uncommon in childhood, but, as a general rule, the 
septa of children are practically straight, and deflections do not become 
troublesome until adolescence. 

Etiology. — Though a traumatic origin due to infraction of the septum 
as the result of blows on the nose is accei:)ted by all authors, this is 
doubtless not as frequent a cause as many sui^pose, as the patient is 
inclined to attribute his trouble to some accident to his nose, however 
slight. The commonest cause of septal deflection is disproportionate 
growth of the septum and the bones that frame it. The upper jaw 
especially is apt to be asymmetrical. The septum will thus become too 
large for its setting, and as the individual grows this disproportion be- 
comes sufficiently marked to cause it to buckle and fill one naris or 
obstruct both, as in the sigmoid form. That this disproportion may 
begin early the cases occurring in infants show. The septum may be 
forced over by nasal tumors, sometimes to an extreme degree ; bony cysts 
of the middle turbinal may also accomplish this, but simple hyx)ertrophy 
of the turbinals cannot displace the septum. 

Pathology. — In simple deflection, whether of the bony or cartilaginous 
part of the septum, its thickness is even and normal throughout, the bone 
or cartilage being merely bent out of shape as one would bend a sheet 
of tin. The deflection of the osseous septum alone is rarely great enough 
to evoke symptoms, and most bony abnormalities large enough to cause 
obstruction are ridges, spurs, or exostoses. The i)osterior part of a car- 
tilaginous deflection may extend back, however, so that the vomer and 
perpendicular plate of the ethmoid at their place of junction are in- 
volved in it and are bent out into the naris ; in fact, a large proportion 
of cartilaginous deflections are carried back into the bony septum in this 
way, adding to the difficulties of their correction. 

391 



392 



DISEASES OF THE NOSE AND NASOPHARYNX. 



The quadrangular cartilage is the place iu which deflections are seen 
oftenest and in their greatest development, and the variety of shape 
presented by these is so great that almost each case is peculiar. The 
degree of bulging of the septum varies from a slight amount hardlj^ ob- 
structing the air-current to protrusions that pack the bent septum tightly 
against the turbinals and close the naris completely. The opposite side 
of the septum shows a hollow corresponding to the elevation on the 
obstructed side. In some cases the deflected septum is curved into one 
nasal fossa in a single bend as seen from above or anteriorly ; this is 
spoken of as the C-shaped form of deformity. In other cases the septum 
bends into one naris above and projects into the other below ; this is 
called the S-shaped or sigmoid septum. Though no two deflections are 

Fig. 147. 




Transverse section through nasal cavity. (Bresgen.) F, deflection and spur which have prevented the 
growth of the middle turbinal ; LM, left middle turbinal. 



precisely alike, there are certain types that often present themselves. 
A common one occupies the front of the cartilaginous septum. The pro- 
jection it causes is visible without a speculum, and usually presents as a 
wedge-shaped vertical angle like the corner of a box pointed across the 
obstructed naris. The upper part of this angular projection merges in- 
sensibly into the upper part of the septum, but the lower part may jut 
out prominently, as if the floor of the box joined the sides. The corner 
may be right-angled, or present an obtuse or acute angle. Instead of 
being vertical, it may extend up and back in the direction of the upper 
border of the vomer. In many cases the anterior surface of the corner 
stretches across the naris, closing it, while the posterior surface, instead 
of sharply receding to the normal plane of the septum within its car- 



DISEASES OF THE NASAL SEPTUM. 



393 



Fig. 148. 



tilaginous part, is very long, and involves both the cartilaginous and 
bouj' septum, which take part in the deflection. 

In another type of deflection the whole cartilaginous and often the 
bony septum are bent in a gentle curve, both vertically and horizon- 
tally; into the obstructed naiis. Still another form, and a common one, 
shows the wall of the septum projecting into the other side, such as the 
finger makes in a tightly stretched cloth. 

A peculiarity of many deflections is that their deepest -psirt in the 
concave side forms a hollow with steep sides, which meet at the bot- 
tom at an angle, while a corresponding sharp projection is seen on the 
convex side. The corner-shaped tyi)e of deflection seems to be the 
commonest. After the deformity of the cartilaginous septum has been 
removed, there is often found a spur or ridge behind it corresponding to 
the ui^per border of the vomer, or this and the perpendicular plate of 
the ethmoid continue the deflection. In adults the average thickness 
of septal deflections is one-eighth of an inch, and 
the deepest and most prominent i)art of them usu- 
ally has the thinnest walls. The lower part of 
the deflection is often thickened to as much as 
three-eighths of an inch. In women the septum 
is generally thinner than in men. Ecchondroma, 
exostosis, and abnormal thickening of the septum 
usually complicate the deflection. 

A x^eculiar form of septal deformity is seen 
when the anterior part of the quadrangular carti- 
lage has been dislocated from the superior maxil- 
lary ridge or even the vomer back of it. In this 
case the lower edge of the cartilage and its an- 
terior inferior angle can be seen projecting into 
one nasal vestibule as a whitish, sharj) ridge be- 
neath the mucous membrane, while the other nasal fossa may be ob- 
structed by a deflection above this, the anterior border of the septum 
thus lying across both nostrils. 

Symjytoms. — The symi)toms produced by deflection of the septum are 
the usual ones of nasal obstruction, and they may appear only when an 
acute or chronic rhinitis causes swelling of the mucosa. A slight degree 
of the latter may then be enough to block the narrowest naris entirely. 
The time when deflections begin to produce obstruction is usually after 
the period of adolescence, when the osseous system is completing its 
development. Many patients, however, in middle life date the trouble 
due to their deflected septa back but a few years, even when a fracture 
has not occurred which could account for the deformity. In these cases 
a chronic swelling of the mucosa has usually develoiDed. It is very 
common to find the turbinals in the naris containing the concavity 
in the septum hypertrophied, and in some cases to such a degree that 




Deflection of anterior por- 
tion of septum in the right 
naris, with hypertrophy of 
the anterior end of the lower 
turbinal in the left. 



394 DISEASES OF THE NOSE AND NASOPHARYNX. 

the nasal fossa which normally would be the roomiest is the most 
obstructed. 

Hypertrophic rhinitis and nasal mucous polypi are frequent accom- 
paniments of septal deflection. The difficulty in clearing the obstructed 
naris of secretion during acute catarrhs causes these to be persistent, and 
leads to chronic hypertrophic rhinitis of the impervious and finally of 
the sound side of the nose. The obstacle to the air- current makes it 
difficult for patients to clear the nasopharynx of secretions, and post- 
nasal catarrh is a common complication. Middle-ear catarrh frequently 
accompanies septal deflection, and great difficulty may be experienced 
in passing the Eustachian catheter through the narrowed nostril, this 
often being impossible. Pressure of the deflection against the turbi- 
nals has in some cases caused their atrophy. Nervous symptoms and 
erythematous, papillary, and eczematous eruptions on the face have been 
attributed to the affection. Though these symptoms may have some 
connection with septal deflection, they certainly are rare copiplications 
of it. When the deflection is great, a prominent symptom is twisting of 
the nose to one side, usually opposite the convexity of the septum. The 
deformity is sometimes very marked from bending to the side of the 
anterior edge of the cartilage, even though there be but little deflection 
farther back. If the deflection be of sufficient degree, the voice will 
have the peculiar dead quality and lack of resonance due to nasal ob- 
struction, and the change in its timbre after a successful operation is 
often very marked and pleasing. Inspection of the septum will show it 
extending across the obstructed nasal fossa more or less completely, so 
that often the parts back of the deflection are invisible. The concave 
side of the septum will present more or less of a depression, which at 
times is surprisingly deep. One may see the signs of hypertrophic rhi- 
nitis, but in a large number of cases the nasal interior looks healthy. 
The surgeon should not be satisfied with merely inspecting the deflection, 
but the posterior nares should be examined by rhinoscopy for obstructing 
hypertrophies of the posterior ends of the turbinals. The thickness of 
the septum can be judged by passing a little finger into each nostril, but 
a septometer will give more accurate results. It is an instrument re- 
sembling the calipers used for measuring the caliber of pipes. 

Diagnosis. — There is no disease with which deflection of the septum is 
liable to be confounded if a careful rhinoscopic examination be made. 

Prognosis. — Most of the evil results of the obstruction can be remedied 
by a suitable operation, and the external deformity may be largely re- 
moved if the nasal bones have not been crushed so as to cause depression 
of the bridge of the nose. 

Treatment. — The numerous operations devised for straightening the 
deflected septum show that many of these have proved unsatisfactory and 
also how difficult the apparently simple task is. The varied forms in 
which septal deflection appears also account for the multitude of methods 



DISEASES OF THE NASAL SEPTUM. 395 

needed to suit different cases. The difficulty of operation is also en- 
hanced by the fact that most deflections are combined in varying degrees 
^ith exostoses and ecchondroses, so that often the deflection becomes a 
minor matter and the exostosis the chief object for operation. It is use- 
less to devote space to anything but those means that are considered best 
to-day, and they are all operative. 

Perhaps more employed than any other at present is the operation of 
the crucial incision through the septum. Though this method is com- 
monly attributed to and named after Morris J. Ash, it was practised 
long before the present era, being in use in 1870. Ash has devised a 
set of instruments for its ready i;)erformance, and his writings have 
brought the operation into prominence in recent times. The reason for 
the popularity of this operation is that it does not require the skill that 
familiarity- with rhinological manipulations can alone give, so that it can 
be performed by the general surgeon. It is largely mechanical, and does 
not necessitate much planning of the work to be done or minuteness and 
deftness in its execution. It is suitable for extreme and difficult deflec- 
tions seated too far back within the nasal cavity to easily be reached 
from in front, but is by no means the only method for every form of 
deflection that many are trying to make it. It is a formidable operation 
for the patient, even if easy for the operator, as general auj^esthesia is 
required, and the large and powerful instruments inserted within the 
nasal fossae may do violence to the structures there. 

Fractures of both the middle and inferior turbinals have been re- 
ported, with complete closure of the inferior meatus and adhesion of the 
lower turbinal to the floor of the naris as results. As usual where 
mechanical methods take the place of manual dexterity, they apply 
themselves perfectly to but a limited number of suitable cases ; for the 
others operations especially planned for the case and performed with 
local anesthesia are much better, and are not followed by the pain that 
the violent manipulations of the septum in the operation as performed 
by Ash cause the patient for the first day or two, nor do they require its 
tedious after-treatment or a stay in bed. 

Those who wish to read an excellent presentation of views differ^ 
ing from those i)resented here are referred to the article of Dr. Emil 
Mayer in the New YorJc Medical Eeeord^ 1898, vol. liii. p. 190. The in- 
struments devised by Ash for the operation are, first, a strong cartilage 
scissors, one blade thick and blunt for introduction into the obstructed 
nostril, the other (the cutting blade) of a curved wedge shai^e, the shanks 
curved outward so as to admit of closing without interfering with the 
columna. The handles are steel, curved like dental forceps. The second 
instrument is a curved gouge for breaking up adhesions that may exist 
between the septum and the turbinal. The third is a forceps with 
stout parallel blades. This instrument is very powerful. The adhesions 
are broken up with the gouge. Then the blunt blade of the scissors is 



396 DISEASES OF THE NOSE AND NASOPHARYNX. 

inserted into the obstructed nostril, the cutting blade into the other. A 
crucial incision is then made in the region of greatest convexity, with 
the cuts as near as possible at right angles to each other. The forefinger 
is then inserted into the obstructed nostril, the segments made by the in- 
cision are pushed into the opposite one, and the pressure continued until 
they are broken at their base and the resiliency of the septum is de- 
stroyed. Ash states that on this point depends the success of the opera- 
tion, for unless the fracture of these segments be assured, the resiliency 
of the cartilage will not be overcome and the operation will fail. Frac- 
ture of a segment, however, that consists wholly of cartilage is not pos- 
sible, and resiliency can only be destroyed if the flajD have a bony base 
at which it can break. The septum is then to be straightened with the 
strong forceps and the hemorrhage checked before proceeding further. 
Tamponing may be required to stop the bleeding, though this may yield 
to a spray of iced Dobell' s solution. Tubes of hard rubber, flattened and 
of various sizes, are next introduced, and should be large enough to fill 
the nasal fossa, the larger one on the side where the convexity was. The 
tube is removed from the naris having the septal concavity next day, the 
one from the side with the convexity after forty-eight hours. It should 
be cleaned, the nasal fossa irrigated, and the tube replaced and removed 
daily, a manipulation that the patient can learn to perform. The tube 
should be worn for from five to six weeks, to prevent recurrence of the 
deformity. The edges of the flaps made by the crucial incision will 
firmly unite, the epithelium being lost from their opposing surfaces. To 
facilitate the making of the vertical cut. Ash has added a second pair 
of scissors, with the blades applied at an angle to the flat of the shank. 
The strong forceps is never to be used to give the septum a twist, as 
fracture of the perpendicular plate of the ethmoid bone might result, 
with serious consequences. The forceps is merely to be used to bring 
the septum into a straight line by closing its blades. Perforations of 
the septum may occur. When the sejDtum is irregularly thickened or of 
great strength this operation is wholly unsuitable. 

Difficulty may be experienced in reducing the deformity by any 
operation mentioned if the septal deflection be continued back into 
the bony septum. To reduce this bony continuation of the deflection 
Eoe has devised a forceps one blade of which is a ring which fits 
into the other blade. With this he breaks up the osseo- cartilaginous 
septum. Eoe calls attention to the fact commonly observed that de- 
flection of the anterior part of the bony septum is almost invariably 
present in deflections of the cartilaginous part. He reduces these by 
the Gleason, Ingals, crucial incision, or other method, or with a knife 
he incises the highest point of the deflection in the shape of a Greek 
cross, bevelling the edges. At the same time, if needed, he makes 
an additional incision along the lower border of the septum. These 
cuts are, if possible, made beneath the mucous membrane and with- 



DISEASES OF THE NASAL SEPTUM. 



397 



out piercing tlie other side. Instead of tubes lie uses tampons for six 
days. 

An oi^eration having also a limited field of usefulness^ but one more 
to be commended than the crucial incision, is Gleason's. Its advan- 
tages over the former are that local anaesthesia is employed, that the 
instruments used are light and not liable to do violence to the interior 
of the nose, and that with the patient in the sitting position they are 
under the intelligent guidance of the hand and eye. The Gleason oi^era- 
tion is especially useful for vertical columnar deviations, though it can 
also be used for horizontal ones. Gleason describes two forms of de- 
flection. In one the septum is thickened so that removing the projection 
on the convex side does not open the opposite nasal fossa, thus avoiding 
a perforation, and such deflections he simply saws away. The second 

Fig. 149. 





Gleason's operation, a, anterior view of septum, dotted line indicates saw cut ; b, lateral view of 
septum, dotted line shows U-shaped flap; c, anterior view of septum, showing flap pushed through 
into other nostril. 



kind of deflection includes the angular, curved, and sigmoid forms. The 
operation for these he describes as the button -hole or flap operation, and 
the instrument used is a Bosworth saw, which is introduced against the 
sejDtum close to and parallel with the floor of the nose. AYith the saw he 
makes a transverse cut until the teeth have penetrated into the cartilage 
or bone ; its direction is then changed until nearly vertical, carefully 
retaining it in a position parallel to the intermaxillary suture. The 
sawing is continued until a U-shaped incision has been made through 
the septum surrounding, except above, the whole deflected area. The 
dotted line (Fig. 149, h, a') shows the position of the saw cut. The U-shaped 
cut is larger on the convex side of the septum. The dotted line (Fig. 
149, «, h') represents the smaller size of the U-shaped cut on the concave 
side of the septum. The result is a button-hole with bevelled edges 
through the septum, covered by a tongue-shaped flap. From the lower 



398 DISEASES OF THE NOSE AND NASOPHARYNX. 

end of the flap and from the portion of the septum upon the concave side 
below the U-shaped incision the mucous membrane is removed with the 
end of the saw or knife, and the flap pushed through the button-hole in 
the septum with the finger-tip, so that the parts assume the position 
shown in Fig. 149^ c. The success of the operation largely depends upon 
the care that is exercised to thrust the flap far enough through the sep- 
tum to enable its lower edge completely to clear the lower bevelled edge 
of the button-hole. When this is accomplished, the resiliency of the sep- 
tum holds the denuded surfaces in contact, and there is little or no danger 
of the flap's returning through the button-hole with a return of the devia- 
tion ; in fact, the flap tends to flatten out its thin bevelled edge in front, 
behind, and below. After the operation Gleason packs with gauze, 
metal, or cork tubes. When the deflection is of the horizontal type the 
flap is often not so well retained, and to prevent its slipping back it 
may be necessary to wear a tube for some weeks. When there is doubt 
whether the redundant tissue of the septum has the required strength 
to hold the flap in its new position, it is well to carry the U-shaped 
incision higher into the perpendicular plate of the ethmoid bone. The 
attachment of the flap to this can then be fractured and thus the resil- 
iency destroyed. Cartilaginous parts of the flap cannot be broken. 

When there is a pronounced deflection, with walls that are not too 
thick, Gleason' s operation is an excellent one ; but when the concavity is 
but slight by reason of a thickening of the septum filling it out, while the 
convexity may be great, the unyielding septal wall is not well designed 
to form a flap, and the opening on the concave side will be too small to 
force the flap through. 

The fact that many deviations have two angles of deflection — a vertical 
and a horizontal one low down on the septum — is the basis of Watson's 
mode of operation. He makes an incision through the septum on its 
convex side from behind forward, just below the horizontal angle, begin- 
ning at the bony septum and extending as far as the deflection reaches. 
The direction of the cut is from below up towards the other side. This 
bevels the incision. The vertical angle is divided also to the other side, 
the cut likewise being a bevelled one. This makes the flaps slide over 
each other. If the angle of deflection be much thickened, it should be 
removed as a wedge. Watson then pushes over the whole of the upper 
part of the septum, which jumps over the lower fragment and hooks 
onto its other side, retaining itself in j)lace. Deflections of the bony 
septum he breaks up with Adams's septal forceps, and the redundant 
thick lower portion on the convex side he removes at once or later with 
the saw. He uses a tenotome for the incision. He tampons with gauze, 
and if the fragments will not stay in place he passes a pin through them, 
beginning in the concave side, passing it through to the convex one across 
the vertical incision and back again to the concave side. The head of 
the pin he covers with rubber. 



DISEASES OF THE NASAL SEPTUM. 399 

John B. Roberts makes a long incision at the most prominent portion 
of the deviation, and to overcome the resiliency of the septum makes 
numerous incisions with a stellate punch. Any horizontal bony edge 
that may remain at the bottom he cuts away with the chisel or saw. He 
then introduces a steel pin into the more open nostril, thrusts its point 
through the anterior portion of the septum, and, after forcing its curved 
part into the proper position, buries the point in the tissues of the pos- 
terior part of the septum on the formerly occluded side. For use in this 
manner the pin should have a smooth glass head to avoid irritation of 
the columnella. It may be left in place about one week. He often intro- 
duces a second pin from the external surfece of the nose just below the 
nasal bones (Fig. 150). 

Beaman Douglass modifies the operation of the crucial incision by one 
in which the cuts are made with the guidance of the finger, and in this 
respect his mode of operating is an improvement 
over mechanical methods. He examines the de- Fig. 150. 

flection for its ridges and highest points with the 
finger before operating. Then he introduces a 
knife, called the spear knife, whose short, sharp - 
pointed blade is attached to the shank at right 
angles. With this he pierces the septum at its 
greatest convexity. He then feels for the point of 
the knife with the finger in the other nostril, and 
makes an incision three-quarters of an inch long. Roberts's operation. 

Into this slit he passes a second probe-i)ointed 

knife, whose blade is attached to the shank in the same manner. With 
this he slits the ridged portions of the deflection, the blade following the 
summit of the ridges for their entire length. In this manner he divides 
the septal deviation into as many parts as there are ridges. These are 
then forced over in the manner already described. 

All the operations described above have this in common, that the in- 
cisions cut through the entire thickness of the septum, and that they 
depend on overcoming the deflection by overlapping of the flaps created. 
This is i^ractical where the septum is of even and normal thickness, but 
in the many cases where all of it is thicker than normal, or where large 
portions of it are transformed into buttresses of thick cartilage, it cannot 
be so neatl}^ folded out of the way, and the redundant tissue, not being 
removed, obstructs the nares. In those methods which dex^end on crucial 
or similar incisions and forcing over and holding the flaps in place until 
united, the natural elasticity of the cartilage will assert itself, the more so 
the thicker the septum, so that there is liability to return of at least a 
part of the deformity. These objections pertain to the procedures that 
have been mentioned, and for this reason Ingals aims at the entire re- 
moval of all redundancy of the buckled septum. The Ingals operation 
is especially applicable to the common angular deflections having a 




400 



DISEASES OF THE Is^OSE AND NASOPHARYNX. 



vertical and a horizontal angle, described as the box-corner shape. 
As a preliminary to its performance the field is ansesthetized on both 
sides of the septum by being swabbed over several times with a solution 
of atropine, one-tenth grain ; strophanthin, one-fifth grain ; oleum carj^o- 
phylli, three minims ; carbolic acid, ten grains ; cocaine muriate, twenty 
grains ; water, enough to make one ounce. The parts are sprayed during 
the last applications of this solution two or three times with the adrenal 

Fig. 151. 



Ingals's submucous cartilage knife (one-half natural size). For destroying resiliency of cartilage 

•without perforation. 

solution mentioned under the treatment of intumescent rhinitis. The 
effect of the adrenal solution is markedly to limit the annoying hemor- 
rhage. About twenty cotton swabs, on long four-cornered applicators 
tapering to a quadrangular i)oint, are needed to wij^e off the blood which 
interferes with vision during the operation. 

An incision is made with Ingals's septum knife or Sajous's knife (Fig. 
152) along the vertical angle from above downward to the horizontal, and 

Ftg. 152. 



Sajous's knife (one-half natural size). 

along this as far as it extends forward. This outlines a flap of mucous 
membrane, which is peeled from the cartilage upward and forward with 
a spud. With Ingals's cartilage knife the bared cartilage is outlined as 
far as the deflection extends forward in the form of an A or triangle with 
the apex upward, its base following the horizontal angle and its forward 
limb keeping close to the base of the mucous flap, which is to be kept 
raised out of the way. The triangular piece of cartilage thus severed at 



Fig. 153. 






Ingals's septum knife (two-fifths natural size). 



its borders is next separated from the mucous surface of the other naris 
with a small, flat spud with sharp edges. This manoeuvre must be 
carried out with great delicacy, as it is easy to perforate the mucous 
membrane into the opposite nostril. A simple slit in this is of no great 
moment, but perforations far forward in the nose within the first inch 
of the septum, unless very small, are apt to be the seat of annoying 



DISEASES OF THE XASAL SEPTUM. 401 

crusts. Back of this perforations (to "be avoided if possible) generally 
do no harm, but may give rise to a whistling sound. This is, however, 
a very rare occurrence, as oi)enings through the cartilaginous septum are 
frequently met with, and patients seldom complain of this symx)tom. 
The moisture of the air back of the first inch of the septum prevents the 
edges of perforations from crusting, as the secretions do not dry. 

Fig. 154. 



lugals's spud (one-half natural size). For lifting flap in operating on septum. 

When the triangle of cartilage is removed the redundant portion 
of the sei^tum in front of the vertical angle is disposed of, and there 
remains yet the portion between the horizontal angle and the base of the 
sei:)tum to remove. This can be taken away by means of a saw, making 
two vertical cuts from below up, one close to the base of the septum 
and the other following; a line at a distance within the crest of the hori- 



FiG. 155. 



-SflARp-*r5MrTFl^ 



Ingals's nasal saw (one-half natural size). 

zontal i3ortion of the deflection equal to the thickness of the septum. 
These cuts are to penetrate into the other nostril. The same result can, 
however, be attained much more easily and quickh' with a large trephine 
driven by a dental engine, the trephine removing the tissue between the 
base of the septum and the horizontal crest of the deflection. The base 
of the deflection having been thus removed, it is necessary to destroy the 

Fig. 156. 




Sharp and Smith's adjustable nasal saw (one-half natural size). The blades cut forward or backward, 
and may be adjusted to any desired angle to the handle. 

resiliency of its ujiper i^art so that it can be brought over to a central 
position. To accomplish this a small trephine, one-eighth of an inch in 
diameter, may be used to take out one or two cores from the septum from 
before backward, or the resiliency may be destroyed by the nasal septum 
cutting forceps (Fig. 157). The cutting may need to be done on both 
sides of the septum, and the set-screw should be used to avoid piercing 

26 



402 



DISEASES OF THE NOSE AND NASOPHARYNX. 



the mucous membrane on the side of the septum opposite the cutting 
blades. These procedures destroy the resiliency of the upper attachment 
of the deviation and permit it to be forced over to the median line. This 
can be done with the finger or septum forceps. The flap should stay in 
place without pressure, as it is absolutely necessary that all resiliency 
should be destroyed, otherwise the deformity will reproduce itself in the 
course of time. As the upper fragment of the deviation swings over to 
meet the base of the septum it closes the perforation made by the saw 
or trephine. 

In that type of deflection i^resenting a curved and not an angular sur- 

FiG. 157. 




Ingals's septum forceps. By removing the screw the cutting blades may be removed. The cutting 
blades are used to destroy the resiliency of the septum in operations for deflection. 

face a trephine suited to the thickness of the sej^tum is introduced into 
the commencement of the bend at its anterior part without a preliminary 
incision of the mucous membrane, and by means of the leverage offered 
by the hand-piece of the dental engine the trephine is made to follow the 
curve of the deflection within its substance until it reaches its posterior 
part, when it re-enters the naris. The trephine follows a horizontal di- 
rection. In this way core after core is removed from the substance of 
the septum, with intervals of about one-eighth of an inch, until it has 
been reduced in material and is sufficiently limp to easily be pushed 

Fig. 158. 




Ingals's heavy bone-scissors (one-third natural size). 



over to the median line. If the resiliency of the septum be not enough 
reduced by the removal of the cores, the bridge between the openings 
can be cut with the cartilage knife. This is entered through a small 
opening in the mucous membrane, and forced back between the mucosa 
and the cartilage ; it is then turned, with the cutting point towards the 
cartilage, more or less obliquely as desired, and drawn forward and 
downward. It does not cut through the mucous membrane on the oppo- 
site side. 



DISEASES OF THE XASAE SEPTUM. 403 

Preservation of the mucous membraue of the seiDtum as much as pos- 
sible is of great importance in operations on this structure, and no more 
should be sacrificed than is absolutely necessary. Eapidity of healing 
is greatly promoted by its remaining intact. 

The after-treatment is simple. Nasal si^atulae are introduced on each 
side of the operated naris as far back as they will go, and a long strip 
of lint thoroughly imx^regnated with boric acid and iodoform or iodol 
powder is packed in between them. They are then withdrawn, leaving 
the tami:)Ou in the naris. The packing is to guard against secondary- 
bleeding rather than to keep the deviation in place, as this should stay 
over of its own accord if the resiliency be destroyed. The lint strip 
also applies the mucous flap to the denuded surface whence the triangle 
of cartilage was removed. The dressing can be taken out on the fourth 
day and, if there be hemorrhage, replaced ; if not, the naris need merely 
be closed with a pledget of cotton to keep out the dust. Irrigations are 
not needed. To prevent crusting, antiseptic oily sprays may be used, 
or vaseline oil from an oil-can may be dropped into the nose by the 

Fig. 159. 




Ingals's nasal spatula (one-half natural size). Sets of three varying in width ; angle of forty-five 

degrees. Made of steel. 

patient. Crusts are liable to form for six weeks after the operation. If 
far forward, an ointment of vaseline and lanolin, each one-half ounce, 
with ten grains of salicylic acid, can be applied with a camel' s-hair 
brush or soft swab by the patient. Ointments stay in place much longer 
than oils, and are therefore more effective. 

In no class of operations is more original thought needed than in 
those for septal deflections. It may be necessary to combine the ideas 
of different methods to suit the case. Those operations done under the 
guidance of the eye with local anaesthesia involve a minimum of trau- 
matism and pain to the patient, and are to be preferred whenever feasible. 

When deformity of the nose and obstruction to respircdion result from 
protrusion of the anterior edge of the triangular cartilage to one side, the 
most satisfactory operation consists in incising the mucous membrane 
over the edge of the cartilage, dissecting it back ui)on both surfaces, and 
then cutting off with scissors all of the cartilage that projects beyond the 
normal plane of the septum into the obstructed nostril. This operation 
not only relieves obstructed respiration but largely remedies the external 
deformity or twisting of the nose. 



404 DISEASES OF THE NOSE AND NASOPHARYNX. 



ECCHONDEOSIS AND EXOSTOSIS OF THE NASAL SEPTUM. 

Ecchondroses and exostoses of the nasal septum occur commonly in 
the form of sharp spines or spurs and as longer ridges or crests. Though 
these may occupy any portion of the nasal septum, there are certain 
places of i^redilection due to the mode of development of the septum. 
The chief of these is the junction of the vomer with the quadrangular 
cartilage and perj)endicular plate of the ethmoid bone. The vomer is 
deeply grooved along its anterior border for the reception of these struc- 
tures. In early life a tongue of cartilage exists between the groove 
of the vomer and the iDerpendicular plate of the ethmoid ; this may ex- 
tend back as far as the alse of the vomer or end short of it. This car- 
tilaginous strip is continuous with the triangular cartilage, and may 
remain unossified till late in life. It may be surrounded by bone, in 
which case it retains its normal dimensions, or one or both of its borders 
may be uncovered by it if one or both of the lips of the von^er's grooA^e 
remain rudimentary. In this case the cartilaginous strij), which is called 
the cartilago vomeris, is relieved from retaining pressure, and grows out 
into one or both nares in the form of a spur or crest, according to the 
extent to which one or both lips of the vomeral groove are defective. 
The crest never extends along the whole length of the vomer on both 
sides, but may do so on one while it reaches part of the way back on the 
other. The proper understanding of this matter is due to the work of 
Zuckerkandl. 

Anteriorly, as far as the quadrangular cartilage extends, crests or 
spurs are generally cartilaginous, though even here they may contain 
bone. Back of this thej^ may contain cartilage in a shell of bone, the re- 
mains of the cartilago vomeris, or the exostosis may be solid bone of 
ivorj^-like hardness, and is almost always troublesome to saw away. The 
perpendicular plate of the ethmoid bone takes but little i)art in the for- 
mation of crests or spurs, but may be deflected if it slip from the vomeral 
groove. Another site in which cartilaginous outgrowths are apt to 
appear is at the anterior part of the septum where this joins the nasal 
floor, just behind the nasal vestibule. Two small cartilages, called the 
vomeronasal cartilages of Huschke, are situated here between the vomer 
and superior maxillary crest, beside the nasopalatine canal. They may 
grow out into cartilaginous protuberances at the foot of the septum of 
large enough size to produce appreciable obstruction. 

Symptoms. — The symptoms are those of deflections just described. 
These formations, because larger and exerting more pressure against the 
outer wall, are more liable to excite neuralgic pain and various other ner- 
vous symptoms than are simple deviations of the septum. They are fre- 
quently found in cases of hypertrophic rhinitis, hay fever, asthma, and 
persistent supra- orbital or occipital neuralgia, but may not have any 
influence on the latter affections. If, as is often the case, the ecchon- 



DISEASES OF THE NASAL SEPTUM. 405 

drosis or exostosis is combined with a deflection, simple inspection may 
not enable one to diagnose its existence or, at least, its extent, and the 
aid of the septometer will be needed. Simple spurs or crests may occa- 
sionall}' be seen protruding on both sides of the septum, but usuallj^ one 
side of this is found normal. The concavity of the septum in the un- 
obstructed naris, found with deflections, will be missing. It may be im- 
possible to tell how for back a ridge extends until it is removed, but 
a probe can usually be hooked around a spur. 

Diagnosis. — As a rule, the diagnosis i) resents no difficulties. The 
points distinguishing ecchondrosis and exostosis from deflections have 
just been mentioned. Soft tumors can be differentiated with the probe, 
which shows the characteristic hardness of bone or cartilage. Osteomata 
and chondromata in their early stages may be difficult to differentiate if 
they originate on the septum. They have a rounded or oval form, while 
septal spurs are pointed and crests i)resent a sharp edge. Later the in- 
flammation of the mucosa, fetid discharge, and increasing and severe 
l^ain caused hy osteoma, with the displacement of neighboring structures, 
make an error in diagnosis impossible. Similar symptoms help to dis- 
tinguish chondroma, which, however, is generally covered with sound 
mucosa. Chondroma is extremely rare. 

Prognosis. — The obstruction maj' be completely removed by suitable 
operation, and many of the symptoms will be relieved accordingly ; but 
the surgeon should not be too confident of the result, for in a considerable 
number of cases some of the symptoms will remain. It is also well to be 
guarded in the i)rognosis as to recurrence of the deformity after oper- 
ation. Though in most cases the wound left after it will heal over 
smoothly, in some persons, especially vigorous young subjects with 
great tissue-forming i)ower, an exuberant callus will replace the si3ur or 
crest wholly or in part, and make a cauterization of the callus or its 
second removal necessary. 

Treatment. — The excessive tissue must be removed by operation, 
during which an efl'ort should be made to save as much of the mucous 
membrane as i^ossible. Before commencing the operation, the sei^tum, 
both upon the affected and upon the opposite side, and all other portions 
of the walls of the cavity liable to be touched should be thoroughly anaes- 
thetized by cocaine in combination with the adrenal solution, as recom- 
mended in the treatment of deflections of the septum. It will be found 
imx^ossible to produce comxDlete anaesthesia by applying cocaine to the 
surface near the nostrils 5 therefore, when the incision is to extend far 
forward, a dro^) or two of the solution should be injected beneath the 
mucous membrane where it joins the integument. Ecchondrosis near 
the nostril may be removed by dissecting u^) the mucous membrane and 
X^aring away the cartilage with a knife, or by cutting it with saws, tre- 
phines, or drills. Drills or trephines can be used with the electric 
motor. De Yilbiss has devised a surgical engine, driven by hand, which 



406 DISEASES OF THE KOBE AND NASOPHARYNX. 

has more power than the comnion electric motor and is preferable under 
some conditions. 

A sharp burr (Fig. 116) may be made to penetrate the mucous mem- 
brane by firm pressure while it is in motion ; and then, by moving it 
slowly aboutj the excess of bony tissue may be cut away without Injuring 
the mucous covering. Any of the debris which is not extruded during 
the drilling process is washed away with a two per cent, solution of 
carbolic acid, ai)plied by a small syringe. 

Ordinary dental burrs will not cut cartilage. Trephiues may be run 
directly through from the front backward, and with care most of the 
mucous membrane may be preserved, but more of it is destroyed than 
when a burr is employed. For removal of ecchondrosis or exostosis 
situated farther back, the mucous membrane should be cut along the 
lower edge of the spur with Sajous's knife (Fig. 152), and the incision 
brought forward and upward in a curved line to the anterior and upper 
portion of the mass to be removed. The mucous membrane is then lifted 
from the subjacent tissues by the back of the same instrument or by a 

Fig. Ifid 




Iiigals's nasal l)one-forceps (one-half natural size). 

spud (Fig. 154) ', a saw is passed beneath the loosened flap at the upi^er 
part of the spur, and a cut made downward on the normal i^lane of the 
septum until it reaches nearly to the lower part of the nasal fossa ; a 
narrow saw is then passed beneath the spur and a cut made directly 
upward to meet the one from above, or the lower part can be cut through 
with the trephine. This may precede the cut from above. After the 
bone is cut through it may be held by soft tissues, and these are cut by 
scissors (Fig. 137) to allow removal of the fragment. Sometimes stronger 
scissors, as shown in Fig. 158, will be needed. Subsequently, any sharp 
spiculee are cut off with bone-forceps or burr (Fig. 116). In cases in 
which the spur is not large, the trephine can be used to remove one or 
more cores as desired. This latter ox)eration is usually performed without 
first having removed the mucous membrane, and the cut is made as much 
as possible beneath it. After the bone is removed the loose flap of 
mucous membrane, which may have been saved above, is pressed down 
smoothly against the septum. 

The patient then blows out the blood ; the cavity is freely dusted with 
orthoform, an antiseptic powder which has the property of inducing pro- 
longed anaesthesia when applied to wounds, or with a powder of equal parts 
of iodoform and boric acid, and, while the flap is held in position with the 



DISEASES OF THE NASAL SEPTUM. 407 

nasal spatula (Fig. 159), the naris is iDacked, as recommended in the treat- 
ment of epistaxis, with a strip of surgeon's antiseptic lint. The strip 
can be made antiseptic by soaking it in a saturated solution of boric acid 
in alcohol, drying, and impregnating it thoroughly with powdered iodol 
or iodoform. It should be kept in a glass-stoppered bottle until wanted. 
The patient is directed to wear it from two to five days if it causes no 
pain or does not become offensive, and then either to return to the oper- 
ator or remove it himself. Usually on the second day, and each day 
thereafter, as much of the tampon as can be drawn out easily is cut off 
and time allowed for the secretions to soften the remainder. Subse- 
quently the wound is kei)t clean and as nearly aseptic as possible, and 
the i^atient directed to use two or three times a day a powder containing 
from twenty to fifty per cent, of iodol. 

Healing usually takes place in from one to six weeks, according to 
the size of the wound, and it is often remarkable that after a few 
months, even when large sj^urs have been removed, the membrane over 
the wound appears normal. H. Holbrook Curtis prefers to remove 
these spurs with the trephine alone ; Bosworth usually employs saws ; 
others are in favor of dental burrs. By using a trephine to cut the 
lower portion when the bone is very hard, and a saw for the upper part 
of the incision when the spur is large, the surgeon is enabled to perform 
the most complete and expeditious operation. The main objection to 
operating with the trephine alone is, that after making two or three 
cuts it will be found that sufficient tissue has not been removed, and the 
parts are so obscured by bleeding that it is difficult to complete the 
oi:>eration accurately ; the effects of the cocaine are liable to pass away 
and much pain will be caused. Perforation of the cartilaginous se^Dtum 
should always be avoided, and an opening should not be made in the 
bony septum if sufficient room can be obtained without it ; but when 
there is a shar^) deflection together with the exostosis, it is often im- 
X)0ssible to free the nostril without opening through to the other 
side. There is, however, no serious objection to this, provided it be 
more than an inch back from the nostril, and in such cases the opening- 
is certainly preferable to a cavity only one-third or one-half its normal 
size. 

Electrolysis can be used successfully for the removal of cartilaginous 
spurs and crests, and though for the great majority a well-planned oper- 
ation is preferable, there are conditions in which the former excels all 
other methods. When a spur or crust regenerates after being sawed 
off, or the exuberant callus even forms adhesions with the outer nasal 
wall, as sometimes happens, electrolysis is a good method for reducing 
the redundant tissue. This is never as hard as the original spur, and 
the needles enter it readih'. The reaction is so slight after electrolysis 
that the removed tissue shows no tendency to reform. An exuberant 
new growth of provisional callus sometimes follows removals of out- 



408 DISEASES OF THE NOSE AND NASOPHARYNX. 

growths after their reduction with caustics^ scissors, or saw. Electrolysis 
is also the best raethod for the removal of exostoses or ecchoudroses in 
people who refuse cutting operations, and who would go unrelieved if 
there were no other way of helping them. Some object to the losing 
of a day or two from business that a bloody operation necessitates, but 
between the sittings of the electrolytic process they can go about as if 
nothing had been done, and no pain or discomfort is felt. It is also 
a method well suited for children, the soft young cartilage and bone of 
whose septa yield readily to the process, while their own and their 
parents' horror of the knife may be insurmountable. When deflection 
complicates ecchondrosis electrolysis is not suitable, but when the latter 
exists without this complication even large outgrowths can be removed 
by patient effort with this method. The apparatus is described under 
hypertrophic rhinitis. The bipolar method, in which both the positive 
and negative needles are thrust into the outgrowth, is the most rapid 
and effective. The needles can be used singly or bound together in 
the manner of a cauterj^ electrode, and the current strength .Should usu- 
ally not exceed twenty milliamperes. The strength of current used 
will depend greatly on the patient's tolerance, and effective work can 
be done with even ten milliamperes. It is well not to extend a single 
sitting beyond six minutes, so that the amount of tissue destruction can 
be watched and perforations avoided. Spurs or crests which have re- 
turned after operation can usually be destroyed in one or two sittings, 
and cartilaginous outgrowths may be softened in two or more. Moritz 
Schmidt says that even bony prominences may be removed in from five 
to eight or even more treatments. As the outgrowth softens in advance 
of the needles, these are to be pushed into the cartilage or bone. There 
is little inflammatory reaction and no after-treatment is needed. The 
sittings should be at least a week apart, to give time for sloughs to 
separate and softened tissues to be absorbed. The current is to be in- 
troduced very gradually by means of the rheostat, and the amount of 
pain can thus be almost mathematically controlled. The pain is often 
referred to the upper incisor teeth on account of irritation of the naso- 
palatine nerve. It should be remembered that this method may lead 
to perforations, and therefore it had better be avoided far forward on 
the septum, within its flrst inch, or at least used here with great caution. 
For other particulars relating to electrolysis the reader is referred to 
foregoing parts of this work. 



PERFORATION OF THE NASAL SEPTUM. 

The commonest form of this lesion is that called idiopathic perforation 
of the septum, or ulcus perforans septi. It occurs exclusively on the 
cartilaginous part, and its existence is usually unknown to its possessor, 
chance or the physician discovering it. 



DISEASES OF THE XASAL SEPTUM. 409 

Etiology. — Among the causes of perforation of the septum are syphilis, 
tuberculosis, lupus, malignant gro-^ths, abscess, haematoma of the septum, 
and operations. A variety of perforation of the septum called idiopathic 
or simple is very common, and in some few instances is congenital, being 
due to incomplete development of the sei)tum. Many idiopathic per- 
forations are caused by picking the nose, and are due to the exten- 
sion of the little erosions and ulcers created thereby. They are often 
found in cement-workers or those whose occupations bring them in con- 
tact with potassium bichromate. These materials gather in the nostrils, 
irritate the mucous membrane, and lead to picking the nose. Other 
cases, Zuckerkandl thinks, are the result of low vitality and local inter- 
ference with the nutrition of the cartilage. These may lead to its atrophy, 
or to its death and perforation if local infection occur. Such conditions 
exist in typhoid fever, phthisis, and other exhausting diseases, and per- 
foration of the septum occurs with some frequency in atroj)hic rhinitis. 

FathoJogij. — In idiox)athic perforation the first lesion is always an 
ulcer on the mucous surface on one or both sides of the septum, and the 
edges of the mucosa can be lifted \\\) from the surface of the cartilage 
when this becomes exx^osed. As the disease advances the cartilage pre- 
sents a defect with sharp edges, and finally perforation of the mucous 
membrane in the other nostril takes i")lace. The pathological appearances 
of the other forms of x)erforation have been considered under the diseases 
causing them. 

Symptoms. — Pain is not a pronounced symptom in simple perforating 
ulcer of the septum, nor is it prominent in the other varieties. The 
X^rogress of the disease generally causes so little annoyance that the 
patient is made aware of it only by the crusts which occlude the nostril 
and lead to rej^eated injury with the finger-nail. Xose-bleed is a common 
symx)tom. 

The most important result of perforations of the septum is deformity. 
This is very rare when only the cartilaginous se^^tum is perforated, as in 
the idiopathic form, even if this be so large as to leave a mere frame of 
cartilage around the oi)ening in the septum. On the other hand, if the 
vomer or x)erpendicular j^late of the ethmoid bone be destroyed, the nose 
is almost sure to recede below the nasal bones, creating an unseemly angle 
with them. This is not invariable, however, as loss of almost the entire 
bony and cartilaginous septum may occur with no appreciable deformity 
of the external nose, much depending on cicatricial x)rocesses which pull 
the latter backward. After x)erforations of the sex)tum have healed they 
present smooth, shar^) borders, generally of healthy appearance. This is 
esx^ecially true of the idiopathic variety. When they are situated far 
forward on the septum they are liable to collect crusts on their circum- 
ference. 

Diagnosis. — For the diagnosis of the various forms of perforation due 
to the diseases mentioned the reader is referred to their respective 



410 DISEASES OF THE NOSE AND NASOPHARYNX. 

articles. Idiopathic perforation of the septum is always limited to the 
cartilaginous portion, while syphilitic perforations almost always involve 
the bony portions as well, though they may destroy the cartilage at the 
same time. Syphilitic perforation limited to the septal cartilage, though 
extremely rare, may occur as the result of perichondritis. 

Treatment — The treatment consists in making suitable applications to 
heal any ulceration that may be present. It is not worth while to try to 
close the opening 5 an attempt, even at best, will afford little benefit, 
and usually results in failure. 

When the cartilaginous rim of the perforation extends beyond the 
mucous lining and is covered merely by cicatricial tissue, it is the seat of 
a permanent raw surface with soreness and crusting. This can be re- 
lieved by paring the mucous membrane from the xDrojecting cartilage and 
removing this with nasal bone- forceps, knife, or scissors, thus forming 
flaps of mucous membrane which, when united, will cover the cartilage 
and do away with the soreness and crusting. 



HEMATOMA OF THE NASAL SEPTUM. 

Hsematoma is a collection of blood beneath the mucope'richondrial 
covering of the septum, characterized by the formation of hemispherical 
tumors on both sides of the sei>tum at its anterior lower part. 

Etiology — Hsematoma may, in rare cases, be of spontaneous formation, 
but is almost always the result of violence to the external nose, producing 
excessive bending or infraction of the cartilaginous sei:)tum. 

Fathology. — In haematoma the effusion of blood usually takes i^lace 
between the quadrangular cartilage and the perichondrium, and does 
not involve the bony septum. The entire septum, cartilaginous as well 
as bony, is composed of two plates, one for each side, united by diplo- 
etic substance. Paul Heymann has found that in many instances the 
blood collects between the plates of the quadrangular cartilage. In the 
usual form of hsematoma the blood lifts the perichondrium from the 
cartilage on both sides of the septum and forms two hemispherical 
tumors, generally symmetrical in location, while the mucous surface over 
these may be unchanged in appearance, or ecchymotic with a purple 
color. The swellings may be seated higher up on the cartilaginous sep- 
tum or near the nasal floor, and their size varies from effusions merely 
producing thickening of the septum to globular tumors that fill the nasal 
vestibule and give a broad appearance to the external nose by distending 
the nostrils. 

Unlike hsematoma elsewhere, in the septal variety the effused blood 
shows no tendency to absorption. In the course of days or weeks the 
contents of the cavity change from blood to bloody serum or pus, while 
the tumor gradually grows. The traumatism causing the hsematoma may 
fracture the cartilage, or this may become necrosed as the result of the 



DISEASES OF THE XASAL SEPTUM. 411 

abscess formation, so that in a few cases perforation results. In most 
instances after opening the hsematoma the perichondrium reapplies itself 
to the cartilage that remains intact. 

Symptoms. — At the time of the accident there is usually some nose- 
bleed, which may be but slight. The pain felt after the injury generally 
soon subsides, and the hsematoma itself causes but little^ if any. For 
this reason patients generally delay seeking advice until some days or 
weeks after the accident, being finallj' led to do so by the discomfort of 
the gradually increasing nasal obstruction caused by the slow growth of 
the hsematoma. 

Diagnosis. — The chief points in the diagnosis of ha3matoma are trau- 
matism, the bilateral appearance of the tumor, the usually normal and 
smooth mucosa over it, its hemispherical form, and feeling of fluctuation. 
These qualities differentiate it from ecchondrosis or exostosis. ]N"asal 
mucous polypi ]3ermit the probe to pass between them and the septum ; 
their appearance is translucent and gelatinous, while the mucous mem- 
brane over a hiematoma is normal or purplish in appearance. Tumors 
of the sei)tum are unilateral and of slow growth as compared with hsema- 
toma. They do not fluctuate, and are generally firm. As abscesses of 
the septum are mostly due to hiematoma, the difference between simple 
hpematoma and abscess can be discovered only by exploratory puncture 
and aspiration and consideration of the etiology. Gumma of the septum 
is not the result of an accident to the nose, and is of slower growth than 
haematoma. It is soon followed by crusts, ulceration, perichondritis, or 
perichondritis with necrosis. 

Prognosis. — Even those h?ematomata ending in abscess usually re- 
cover, the i)erichondrium reapplying itself to the cartilage. Perforations 
rarely result. The course of the disease generall}' extends over weeks and 
months, as the patient seeks help late and the perichondrium is slow in 
reuniting with the cartilage, so that treatment is needed for some time. 

Treatment. — The proper treatment is by iDcision, and the cut should be 
extensive, as the opening shows a great tendency to close again. In some 
cases it may be necessary to follow the plan of Schiiffer, and excise an 
elliptical piece of mucosa and iDcrichondrium with scissors. After open- 
ing the cavity, it should be packed with iodoform gauze or some substi- 
tute until healing occur. If there be an opening in the septum, incision on 
one side may suffice for drainage ; if the septum be intact, it is necessary 
to incise both sides. 

ABSCESS OF THE NASAL SEPTUM. 

Abscess of the septum may take an acute or a chronic course. Acute 
abscess is usually the result of hgematoma, erysipelas, typhoid fever, or 
small-pox ; chronic abscess is generally due to syphilitic infection, but 
arsenic, copper, and mercurial poisoning have been assigned as causes. 
Perichondritis is the basis of all abscesses of the septum not traumatic. 



412 DISEASES OF THE NOSE AND NASOPHARYNX. 

The mucous membrane of the septum has no submucous tissue, but 
is directly attached to the cartilage or bone, its deepest layer taking the 
5>lace of the periosteum or perichondrium ; therefore any lesion pene- 
trating the mucous surface is likely to lead to perichondritis or peri- 
ostitis, with shutting off of the supply of nutrition to the cartilage and 
bone and their consequent necrosis. As these lesions affect, as a rule, 
the anterior part of the septum, simple abscess of the latter is practi- 
cally confined to the cartilaginous portion, and presents the appearances 
described as pertaining to hsematoma. Syphilitic abscess, however, is 
more destructive, and in nearly all cases extends back to the bony sep- 
tum. Syphilitic abscess of the septum results from a gummatous infil- 
tration of the mucous tissues. When seen before they have opened, 
syphilitic abscesses present very much the same appearance as the simple 
form. The same swellings of rounded shape are seen filling the nasal 
vestibule and hiding the parts back of this from view, the mucous mem- 
brane over these is apt to appear red and inflamed, more so than in 
simple abscess, and the swelling is quite painful to the touch. When 
syiDhilitic abscesses are opened, however, the difference between their 
destructiveness and the slight, if any, damage done by simple abscess 
becomes apparent. In syphilitic periosteal abscess the probe finds car- 
tilage and bone necrotic, and the characteristically foul odor from the 
decay of these structures soon sets in. It is, therefore, well to consider 
that an apparently simple abscess may, upon being opened, prove of the 
destructive syphilitic variety. The treatment of simple abscess is that of 
hsematoma. Those of syphilitic origin are to be treated as suggested in 
the article on nasal syphilis. 



CHAPTEE XT. 

ACUTE A^'D CHROXIC RHIXOPHARYXGITIS. 

ACUTE EHIXOPHARYNGITIS. 

Sy n o ny me s.— Acute postnasal catarrh, acute retronasal catarrh. 

Acute catarrh of the xasopharyxx is a frequent and important 
disease. It would be of less consequence were it not for the aural com- 
plications that often accompany it. 

Etiology. — Xo disease better exemplifies the evil results of undue ex- 
posure to cold, esiiecially by those unused to it, than rhinoi^haryngitis. 
In some individuals it follows a wetting or prolonged chilling so promptly 
that its victims can almost count on its aj^pearance. It is probable that 
exposure to cold merely diminishes the local resistance to infectious 
germs which find the nasoj)harynx, so rich in lymphoid tissue, a favor- 
able place for invasion. This is further emphasized b}" the fact that the 
course of most cases of acute rhinopharyngitis is that of an acute infec- 
tious disease, with fever and purulent secretion, and hy the occurrence 
of rhiuoi^haryngitis with certain general infectious ailments, especially 
scarlet fever, in which disease it creates marked sym^^toms. Some sui>- 
pose that the lymphoid tissue of the nasopharynx is the gateway through 
which the germs of many of the general infections enter the organism. 
The infectious nature of many cases of idio^^athic rhinoi^haryngitis in 
children is shown by the simultaneous enlargement of the submaxillary 
lymph-glands. Acute rhinopharyngitis often follows acute rhinitis, but 
may precede it. 

In the fibrinous forms of acute postnasal catarrh the microbes which 
have been found are the staphj'lococcus pyogenes aureus, the strepto- 
coccus pyogenes, and the diplococcus pneumoniae. 

Acute rhinopharyngitis is often the first manifestation of influenza, 
the bacillus of this disease having effected its lodgement in the lymphoid 
tissue of the nasopharynx. 

Pathology. — The pathological changes presented by the acutely in- 
flamed nasopharynx are often associated with an acute inflammation of 
the oropharynx in adults, but seldom so accompanied in children, in whom 
the disease is apt to confine itself to the postnasal sj^ace. The character 
of the inflammation is greatly affected by the presence to a greater or less 
degree of the normal lymphoid elements of the nasoi^harynx. When 
these exist in a large mass, as they generally do in childhood, the}' form 
what is called Euschka's tonsil, a structure which has usually atrophied 
by the time adult life is reached. In acute rhinopharyngitis in children 

413 



414 DISEASES OF THE NOSE AND NASOPHARYNX. 

the acute swelling of Luschka's tonsil becomes the dominant pathological 
factor, SO that its increased bulk may fill up the nasopharyngeal space 
in a day or two and arrest nasal respiration. The first noticeable change 
in rhinopharyngitis is redness of the mucous surface. This may pre- 
sent all hues, from deep red to scarcely discernible change in color. The 
color changes may be local on one side only or involve the whole post- 
nasal space. In a few cases in which the hypergemia is very great it may 
be accompanied by small hemorrhages. Swelling of tissue is a more 
prominent feature than changes of color. When x>osterior rhinoscopy is 
possible, if there be a swollen Luschka's tonsil, this will present as a 
bluish-pink, oedematous mass that makes inspection of the other parts 
difficult or impossible. Its surface may be nearly smooth, divided by 
longitudinal or transverse sulci into prominent ridges, or studded by fol- 
licular plugs like those seen on the faucial tonsil in lacunar tonsillitis. 
When Luschka's tonsil is small or absent, therefore chiefly in the adult 
type of the disease, the mucous membrane of the postnasal space is 
swollen into folds. These may be especially prominent in the fossa of 
Eosenmiiller, while the lips of the Eustachian orifices may also appear 
large and oedematous. The mucous lining of the Eustachian tubes often 
swells so as to occlude their lumina, and the same condition accompanies 
acute rhinopharyngitis in children, though the enlarged Luschka's tonsil 
hides it from view. Especially in children the inflammation may occa- 
sionally take on a fibrinous character, false membrane appearing in the 
nasopharynx, chiefly on Luschka' s tonsil. 

In the earlier stages of acute rhinopharyngitis the secretions are of a 
mucous character, but soon become purulent, and in some cases even 
bloody. Later in the disease the discharge usually becomes jDasty and 
semifluid, and is apt to adhere to the roof or walls of the nasopharynx, 
or hang down from its vault as a curtain. Still later the secretions often 
dry into crusts which are very adherent and are removed by hawking. 

The microscopic appearances are much the same as those found in 
acute rhinitis, as the histological structure of the mucosa of the naso- 
pharynx is essentially like that of the nasal mucous membrane. The 
lymphoid or adenoid layer of tissue is, however, present to a much greater 
degree, so that this part of the structure adds greatly to its size by dense 
round-celled infiltration, and, when Luschka's tonsil exists, augments its 
bulk. It, however, is less causative of the swelling of the mucosa than 
is serous effusion into the intercellular spaces. 

Symptoms. — These are greatly modified by the presence or absence of 
Luschka's tonsil, and, as this is practically a structure of childhood, the 
symptoms of the disease in early life are essentially different from those 
in adults. 

The acute rhinopharyngitis of children usually sets in with fever 
like a general infection. This varies in temxDerature from 101° to 104° 
F., and may be continuous and last from a few days to one or two weeks, 



ACUTE AXD CHRONIC RHIXOPHARYNGITIS. 415 

or even longer. At the same time tlie child, who may have had hereto- 
fore normal respiration through the nose, begins to use its mouth for 
breathing, while its voice acquires the peculiar quality due to blocking 
of the nasal passages. The parents are distressed by its snoring, noisy 
respiration while asleep, to which is often added a rattling sound due 
to the secretion in the nasopharynx mixing with the air-current. In- 
spection generally shows the nose, oropharynx, and tonsils normal in 
appearance, while swelling and sensitiveness of the lymi^hatic glands 
back of the jaw indicate a hidden source of infection. As posterior 
rhiuoscop}^ is impossible, or at least very unsatisfactory in little children, 
the diagnosis must be made from the S3'mi3toms. It is not advisable 
to attempt to confirm it hj passing the finger into the nasopharj'ux, as 
such handling would add to the inflammation ; and if one find the type 
of breathing described and the nares clear, it is XJractically certain that 
the obstruction of respiration is due to inflammatory enlargement of 
Luschka's tonsil. In older children or adults this condition may be 
directly visible by posterior rhinoscopy, and will present the ajDi^ear- 
ance described above under pathology. A frequent complication of the 
affection in children is otitis media, which generally terminates in suj)- 
puration with j^erforation of the membrana tympaui. In older children 
the physician is led to suspect ear trouble on account of comj^laints of 
pain in the affected ear, but in little ones the aural complication may 
be overlooked until a running ear draws attention to it. The advent 
of the otitis media may be marked bj" sudden increase of fever, somno- 
lence, great restlessness, and vomiting. Even convulsions laay occur, 
and with the other symptoms lead to a suspicion of meningitis. In 
milder cases the membrana tympani becomes reddened, but the otitis 
media remains of a catarrhal nature, and does not perforate the drum. 
The snoring, rattling of secretions, and mouth-breathing may last some 
days or weeks and normal nasal respiration be gradually re-established, 
or the disease may terminate in permanent enlargement of Luschka's 
tonsil, or so-called adenoid vegetations. 

During the course of the disease the children do not complain of sore 
throat, but often of pain in the back of the head and of aching over the 
eyes. On account of the enforced mouth-breathing the lips and throat 
become dry and the tongue thickly coated. 

In adults acute rhinoi^haryngitis generally takes less the infantile 
form of an acute and at times severe infection with marked general 
symptoms than of a local process. In mild cases there may be no rise 
in temperature, in those of medium severity it seldom exceeds 101° F., 
while in the severe grades quite high temperatures are occasionally 
found. Even in the mild cases there are malaise, headache, and loss 
of a]3petite quite out of i)roi)ortion to the slight importance of the 
disease. While swallowing causes pain which may be acute enough 
to keep the patient awake, he cannot locate it definitely^ but has the 



416 DISEASES OF THE NOSE AND NASOPHARYNX. 

general sensation of a sore throat. The swelling of the pharyngeal 
mncosa is hardly enough to alter the timbre of the voice, unless the i30S- 
terior ends of the turbinals become cedematous as the result of a com- 
plicating rhinitis. Almost as great distress as that caused by the sore 
throat results from the tough secretion, which has to be removed by 
drawing back through the nose and scraping the throat. When, after a 
few days, the discharge becomes viscid and dries into tough masses, and 
even crusts, its removal becomes very difficult, and may be attended by 
slight bleeding that alarms the patient. The inflammation rarely re- 
mains confined to the naso]3harynx, but generally terminates in an acute 
rhinitis or passes down the oropharynx to the larynx "and trachea. In 
a few cases, even not severe ones, the lymphatic glands of the region 
back of the jaw and some of those of the neck may enlarge and become 
tender. Aural complications are quite as common as in children, but 
usually take the form of acute catarrhal otitis media, with no pain, but 
more or less deafness, which is usually transient. In the higher grades 
of acute rhinopharyngitis in adults there may be a great deal of puru- 
lent secretion produced in the nasopharynx, and even abscesses form at 
times in this region. Sux)i)urative otitis media, with often large per- 
forations, may occur, and mastoiditis and other serious comi)lications 
result. The fever runs a prolonged course and the illness is severe. An 
average case of acute catarrh of the nasopharynx in adults lasts a week 
or ten days. The fibrinous form tends at times to become subacute and 
extend over weeks. 

Diagnosis. — The acute onset of .mouth-breathing, fever, and swollen 
submaxillary glands and the absence of intranasal obstruction sufficiently 
distinguish the ailment from adenoid vegetations. In many childi^en 
affected with these, however, the vegetations become the seat of repeated 
inflammation, so that attacks of complete or almost complete arrest of 
nasal respiration, with fever, are followed by periods during which the 
child may breathe fairly well through the nose. 

In adults posterior rhinoscopy usually makes the diagnosis easy. 
Only cultures obtained from secretion swabbed from the nasopharynx in 
fibrinous postnasal catarrh can distinguish the disease from diphtheria of 
this region. The culture should, however, not be waited for, but antitoxin 
injected immediately and the case treated as a diphtheritic one. 

Frognosis. — This is generally favorable as to the rhinopharyngitis, 
but the result of the aural complications cannot be foreseen. 

Treatment. — In little children local treatment is impossible, and, if it 
were not, would be, as in most acute microbic invasions, of little benefit 
to the affected tissues. The fever can be modified by antifebrin or 
other antipyretics, and in some mild cases antifebrin or the salicyl- 
ates seem at times to shorten the course of the disease. Local appli- 
cations to the neck only annoy the child. When the secretions seem to 
collect in the nasopharynx, their removal can be aided by dropping into 



ACUTE AXD CHROXIC RHIXOPHARYXGITIS. 417 

the child's nose about ten drops of a mild alkaline solution ; for instance, 
a half- drachm of sodium bicarbonate to a tumblerful of water. In the 
adult rhinopharyngitis is often favorably influenced by salol or sodium 
salicylate. Antifebrin is useful in feverish cases, and quinine in large 
doses once or twice daily tends to cut short the disease. 

Locally, in the first days of the ailment, a spray of cocaine, one grain 
to the ounce of a saturated boric acid solution in water, may be used by 
the patient, and will give relief to the dysphagia. If sprayed directly 
back along the nasal floor it reaches the nasopharynx, especially if the 
patient be in the recumbent position. Later, when the secretions begin 
to collect and annoy the patient, they may be washed away with Freer" s 
nasal irrigating tube, a solution of potassium permanganate strong enough 
to have a light pink color being used. When the secretions have a ten- 
dency to dry and crust in the nasopharynx, oily sprays of oleum i^etro- 
latum album will dissolve the masses. This spray should be used by 
the patient himself, or he may employ, if skilful enough, a fine brush 
on a long, thin handle, to convey vaseline jelly into the posterior part 
of his nose, whence the oily matter will spread over the postnasal space. 
The oil-can with vaseline oil, mentioned in other parts of this work, may 
be employed. 

CHROXIC EHINOPHAEYXGITIS. 

Synonymes. — Postnasal catarrh, retronasal catarrh, follicular disease of the 
nasopharynx. 

Chronic rhinopharyngitis is a chronic catarrh of the nasopharynx 
often associated with the same condition in the oroi:)harynx and larynx, 
but usually, at least in America, not descending below the postnasal 
space. Chronic rhinitis in some of its forms very frequently accom- 
panies the disease. Postnasal catarrh is so much more frequent in Amer- 
ica than elsewhere that Mackenzie called it American catarrh. It is the 
ailment sj^oken of by the laity as '^catarrh," and is much advertised by 
quacks to terrorize the ignorant. 

Etiology. — Chronic catarrh of the nasopharynx is commonest between 
the ages of twenty and fifty, and is therefore properly a disease of adult 
life. The chronic catarrhal symptoms occasionally associated with ade- 
noid vegetations in children yield on the removal of these growths, and 
are merely symptomatic. Among the remoter causes of chronic rhino- 
pharyngitis are living in badly ventilated, dusty rooms, breathing an 
atmosphere full of tobacco-smoke, and abiise of the voice. Alcoholic 
excesses are very prone to cause the form associated with catarrh of the 
oro])harynx which leads to hawking, retching, and vomiting in the 
morning. 

In climates subject to sudden and extreme changes of temperature the 
disease is very fi-equent. Diminution of the proper supplj^ of moisture to 



418 DISEASES OF THE NOSE AND NASOPHARYNX. 

the air^ such as occurs in overheated houses, tends to perpetuate acute 
attacks of rhinopharyngitis, as the secretion dries on the mucous surface 
of the nasopharynx and keeps up a chronic irritation. Freudenthal, of 
New York, asserts that the normal atmosphere contains, as a minimum, 
from forty to fifty per cent, of moisture, and that in summer it often has 
from eighty-five to ninety per cent, of its maximum saturation. On the 
other hand, in theatres, dwellings, and other localities heated by artificial 
means he found from forty down to ten per cent., an amount of moisture 
less than that in the driest climates. Even in New Mexico the percentage 
of watery vapor is from fifty to sixty. To overheated houses, therefore, 
with very dry air he attributes the frequency of postnasal catarrh in 
America. The gouty diathesis, rheumatism, and chronic gastritis are to 
be considered as predisposing causes. Among the exciting causes fre- 
quent acute nasopharyngeal catarrhs are not etiological factors to so 
great an extent as one would naturally suppose ; in fact, .most of these 
recover completely. Excessive size of the nares is liable to cause chronic 
rhinopharyngitis by not permitting the air breathed to come intimately 
enough in contact with the surface of the nasal mucosa to gain suffi- 
cient moisture. Dust, also, is not arrested in the nares, but is carried 
directly back into the nasopharynx, and this is one of the reasons why 
the disease is so often associated with atrophic rhinitis. Extension of 
chronic rhinitis backward or of chronic catarrh of the pharynx upward 
may lead to the disease, as also may nasal obstructions from whatever 
cause, such as polypi, hyx)ertroi)hic rhinitis, septal deflections, etc. In 
these cases mouth-breathing creates oral and pharyngeal irritations by 
contact with an air-current not freed from dust and warmed as it would 
be by passage through the nose. These lead to ascending catarrh of the 
oropharynx and involvement of the nasopharynx by continuity. Though 
many patients with nasal obstructions complain of frequent hawking of 
mucus from the nasoi)harynx, nevertheless, in a large proportion of cases 
the nasopharynx remains perfectly healthy. Those whose employments 
expose them to the inhalation of irritating dust are peculiarly liable to 
the disease, and this is also true of patients with valvular disease of the 
heart or lung diseases obstructing the venous circulation. Many cases 
are apparently caused by submucous thickening at the sides of the pos- 
terior part of the vomer. The direct relation of this thickening to the 
discharge and chronic inflammation cannot be. explained, but its etio- 
logical relation is clear, as the reduction of the thickening will often 
greatly benefit, if not completely cure, the postnasal catarrh. 

Pathology. — In many cases pronounced symj^toms exist for years with- 
out the mucosa presenting anything appreciably abnormal on the most 
careful inspection, so that one is inclined to regard these cases as anom- 
alies of mucous secretion rather than chronic inflammation. Other 
cases show more marked pathological changes, and are apt to be asso- 
ciated with hypertrophic or granular pharyngitis of the oropharynx, 



ACUTE AND CHRONIC RHINOPHARYNGITIS. 



419 



intumescent rhinitis, or often with atrophic rhinitis. Chronic rhinophar- 
yngitis accompanying the latter affection is apt to end in atrophy of the 
mucous membrane of the nasoi)harynx. The surface of the mucosa in 
these cases of chronic rhinopharyngitis is usually reddened and vascular, 
but may in some cases be even paler than normal. The mucous mem- 
brane is thickened and boggy in appearance. Microscopically, the epi- 
thelium shows an extension uj)ward of the pavement epithelium of the 
oropharynx to a greater or less degree ; in other places the epithelial 
surface is lost, or the ciliated cells are replaced by layers of cuboid ones. 
In children the ciliated epithelium normally extends downward on the 



Fig. 101. 



Fig. 162. 




Adenoid tissue at vault of pharynx. Poste- 
rior wall of upper part of pharynx. (Luschka.) 
1, 1, pterygoid process ; 2, section of vomer ; 
3, 3, posterior portion of the vault of the nasal 
fossae ; 4, 4, pharyngeal orifice of the Eu- 
stachian tube ; 5, orifice of the bursa pha- 
ryngea ; 6, 6, recessus pharyngeus ( fossa of 
Rosenmiiller) ; 7, median folds formed by the 
adenoid substance of the nasal portion of the 
pharynx. 



mm 




Vww^^ 



Pharyngeal bursa. Antcio-postenor 
section. (Luschka ) 1, section of basi- 
lar process of the occipital bone ; 2, body 
of sphenoid ; 3, pituitary gland ; 4, ad- 
enoid substance of the vault of the 
pharynx, behind ^vhich is seen (5) the 
pharyngeal bursa. 



posterior wall of the nasopharynx as far as the velum, while in adults it 
reaches only about one-third of the way down this surface. The connec- 
tive tissue is increased in quantity and the lymphoid follicles are often 
found in a state of cheesj" degeneration, or may have broken down into lit- 
tle ulcers. The outlets of the mucous glands are dilated, filled with round 
cells, and their epithelial lining may be in a state of fatty degeneration. 

In this connection the so-called bursa pharyngea is to be considered. 
Luschka describes the bursa pharyngea as a sac-like recess in the pha- 
ryngeal vault, at the most one and one-half centimetres long and six 
millimetres wide. It ascends, penetrating the periosteum of the body 



420 DISEASES OF THE NOSE AND NASOPHARYNX. 

of tlie occipital bone. The sac lies against the posterior wall of the 
pharynx. It is situated near the lower and posterior part of the pha- 
ryngeal tonsil in the median line, and its opening is of the size of a pin's 
head. This is the pharyngeal bursa of Luschka. It is present in a small 
number of individuals, and is a natural formation dating from birth. 
Other authors mean by the pharyngeal bursa not only this cul-de-sac of 
Luschka, but any similar recess in the centre of the pharyngeal vault, 
even if of pathological formation. Bursse of this type generally result 
from an unusually deep recessus pharyngeus medius, or central fissure 
of the pharyngeal tonsil. The bottom of this fissure remains attached to 
the periosteum of the roof of the pharynx, while its borders agglutinate 
and form a covered recess resembling the normal bursa. If this variety 
be added to the true bursa of Luschka, such tissue in the pharyngeal vault 
may be considered reasonably frequent. In whatever way a mucous 
pocket or cul-de-scic is formed, it can readily be understood that it pre- 
sents a favorable seat for chronic, ill-drained suppuration, and that 
closure of its outlet may result in its distention from retained, secretion. 
Disease of its inner lining is apt to lead to the formation of cysts, due to 
retention of the contents of occluded mucous glands. These cysts may 
be as large as a pea. The pharyngeal bursa may be the only part of 
the nasopharynx in a state of chronic inflammation. 

In the atrophic form of chronic rhinopharyngitis the mucous surface 
of the entire nasoj)harynx may become pale, smooth, and atrophied. The 
adenoid or lymphoid tissue which forms so large a part of the normal 
mucosa of the nasopharynx almost disappears. The connective tissue 
is increased in quantity and the mucous glands are much diminished in 
number. The atrophic form of chronic catarrh of the nasopharynx is 
most often found in elderly people. 

Syynjjtoms. — The disease seldom causes x>ain in the throat or actual 
dysphagia, but rather a feeling of dryness and a raw sensation in the 
nasopharynx, intensified by swallowing. This may be associated with 
a tickling cough when the secretions flow down into the larynx. The 
patient complains of a sensation of secretions dropping from the naso- 
pharynx into the oropharynx, and of a constant desire to hawk and 
clear the throat, even after the irritating secretion has been entirely 
removed, as the nerve-flbres of the diseased mucosa are hypersesthetic. 
Some patients mention the sensation as of a foreign body in the throat. 
Though there be no pain in the throat, other nervous symptoms may be 
annoying, such as dull frontal or occipital headache, pain in the nape of 
the neck, and a heavy, tired feeling in the head. As chronic rhinitis 
is, however, so often associated with the disease, it is hard to tell whether 
or not these pains depend. wholly on the rhinopharyngitis. The voice 
frequently suffers, either because of accompanying laryngitis or because 
masses of secretion block the posterior nares, at times suddenly getting 
in the way of the air- current, or else the chronic inflammation relaxes 



ACUTE AND CHRONIC RHINOPHARYNGITIS. 421 

the mucosa and the tone of the muscular coat of the pharynx, so that 
its walls lose their smoothness and proper tension during phonation. 
The discharge may be simplj^ muco-pus or quite purulent, and in very 
many cases the secretion is altered in quality, showing a tendency to 
insi)issation, so that the hawking of tough leathery or dry crusts, at 
times with blood, is a feature of the disease. This may continue all day, 
but in most cases the patient scrapes the accumulated secretions away in 
the morning and clears his throat much less at other times. Eetching, 
strangling, and vomiting often accompany the morning toilet of the naso- 
pharynx. 

In some cases, but by no means a majority, there is associated with 
the chronic rhinopharyngitis chronic middle-ear catarrh, with deafness 
and tinnitus aurium. ^Yhen this occurs with chronic catarrh of the 
nasoi)harynx it is almost invariably attributed to it, but seems, at least 
in many cases, to be a mere coincidence. Chronic otitis media is more 
frequently found in connection with a normal nasopharynx than with 
l)ostnasal catarrh, and, though it may result from the latter, it so often 
constitutes an independent affection that it is not wise to tell a i)atient 
that relief of his catarrh will improve his hearing. Inspection may 
show the glue-like secretion flowing down the posterior wall of the oro- 
pharynx and coating it with a varnish-like surface. When this is re- 
moved the orox^harynx may be found normal, or more rarely it may 
present the appearance of granular or chronic hypertrophic inflamma- 
tion. Posterior rhinoscopy commonly shows a mass of dried or semi- 
fluid purulent secretion in the centre of the j^haryngeal vault, which 
may be limited to the region of a true or i^athologicallj^ formed bursa 
or the central fissure of Luschka's tonsil, while the rest of the naso- 
pharynx is healthy. In other cases the vault of the pharynx, the 
choanse, and, more rarely, the region of the Eustachian orifices may be 
hidden by discharge. After the latter has been washed away the naso- 
pharynx may present a normal appearance or the changes in color and 
the swelling mentioned in the i^athology. Often the patient's efforts 
during the day have dislodged the secretion, so that the most careful in- 
siDCCtion presents nothing abnormal, and his comi)laints seem without 
reason. If, however, a case of this kind be examined in the morning, 
before the discharge has been scrai)ed away, it can be seen in the naso- 
l^harjnx, as described above. In ]3rotracted cases swelling and relaxation 
of the soft palate may occur. In addition to the hypersecretion of the 
bursa pharyngea, which presents the ai)pearance of i^us or crusts in the 
neighborhood of its outlet, cysts which have formed in it may at times be 
visible, producing rounded prominences varying from the size of a pea 
to that of a hazel-nut ; they have a yellowish- red color and can be com- 
pressed with the probe. In this form of bursal inflammation the patient 
feels, as it were, the presence of a foreign body, irritation and pain in the 
nasopharynx, and pain may also be felt in the head. 



422 DISEASES OF THE NOSE AND NASOPHARYNX. 

In the condition spoken of as rliinopharyngitis sicca the dried secre- 
tions cover the mucosa of the nasopharynx extensively, in some places 
forming a mere film that gives the mucous surface a varnished appear- 
ance, in others adhering in the form of crusts, often of great extent and 
thickness. This condition does not necessarily indicate atrophic rhino- 
pharyngitis, as when the dry coat of secretion is removed one may find 
the mucosa even hypertrophic ; so that rhinopharyngitis sicca is not an 
anatomical variation of chronic catarrh of the naso]3liarynx, but merely so 
named from the dry api3earance of the mucous surface. It is, however, 
most commonly found with the atrophic form of chronic catarrh of the 
nasopharynx. This often accompanies atrophic rhinitis, but may exist 
independently of it. It is characterized by the pale aj^pearance and 
thinness of the mucous membrane which become apparent after the 
pharyngeal vault has been cleansed of secretions. In atrophic catarrh 
no trace of lymphoid tissue is found in the region of Luschka's tonsil, 
as this structure entirely atrophies. 

Diagnosis. — The affection most liable to be confounded with chronic 
rhinopharyngitis, though often itself a cause of it, is disease of the pos- 
terior ethmoidal cells or sphenoidal sinus. The secretion from these 
cavities flows backward and dries on the pharyngeal vault, or lodges in 
the choanse, or covers the Eustachian orifice. 

The diagnosis is difficult. In sinus disease, after removal of the secre- 
tion, the nasopharynx seems normal unless there be a coexisting rhino- 
pharyngitis. In empyema of the sinuses pus may be seen flowing down 
along the septum in the olfactory fissure, while the middle turbinal is 
swollen and chronically inflamed. In chronic catarrh of the naso- 
pharynx the appearance of the nasal fossae is either normal or charac- 
teristic of a chronic rhinitis. Empyema of the posterior ethmoidal cells 
or sphenoidal sinus is accompanied by the severe x)ain described under 
these affections, while the nervous sym^^toms of chronic catarrh of the 
nasoi:)harynx are vague and less pronounced. 

It is possible to mistake adenoid growths or other tumors of the 
nasopharynx for chronic rhino j)haryngitis, but posterior rhinoscopy will 
reveal their widely different features. If this cannot be used, palpation 
of the nasopharynx must be resorted to. In chronic rhinoi)haryngitis 
it is i^ossible for accumulated secretions to simulate the symptoms of nasal 
occlusion caused by adenoid growths, but they are very seldom present 
in sufficient quantity to cause any obstruction to breathing. 

Syphilitic disease of the nasoi^har^^nx may cause great destruction 
in its tertiary stage, while the patient and his physician, if the latter 
do not use posterior rhinoscopy, may believe that only a chronic catarrh 
exists. If pains be not taken to remove all secretions and crusts from 
the nasopharynx, even posterior rhinoscopy may not reveal the existing 
ulcerations. Deep tertiary ulcers on the i)Osterior surface of the soft 
palate may escape observation because of diificulty in getting an image 



ACUTE AND CHRONIC RHINOPHARYNGITIS. 423 

of this region in the mirror. If the latter be bent so that it is attached 
to its handle at a right angle, this obstacle is removed and the part in 
question can usually be seen. The main reliance in distinguishing sj' phi- 
lis of the nasopharynx from chronic rhinopharyngitis is posterior rhi- 
noscoi)y, unless other symptoms of syphilis be manifest. 

Frognosis. — The disease may extend over a period of many years, but 
is not dangerous to life, and, contrary to the popular belief, which is 
fostered among the \2dtj by designing charlatans, there appears to be no 
tendency for it to extend downward and eventuate in pulmonary tubercu- 
losis. AYhen the affection has lasted many years it is doubtful whether 
it is often cured ; but in the majority of cases caused by nasal occlusion 
removal of the obstruction will greatly relieve, if not cure, the disease 
in the nasopharynx. 

Treatment. — The prophylaxis includes whatever tends to increase the 
individuars resistance and bodily nutrition, especially the correction of 
the so prevalent underfeeding due to hurried meals. Cold showers and 
frictions greatly lessen the tendency to exacerbations, which are apt to per- 
petuate the disease. Even if it be troublesome to him, the patient should 
be enjoined to change his underclothing to meet the changes in weather, 
and not to go about sweltering in woollen undergarments in sum- 
mer, imagining that he is taking esi^ecial care of himself, while he is 
really making himself tender and weak and more liable to colds. It is 
impossible to avoid exposure to sudden changes of temperature, but 
the evil effects of overheated rooms can be mitigated by keeping the air 
moist, and those afflicted with dry catarrh will find it of benefit to hang a 
wet blanket in the sleeping-room. Those working in dust should be urged 
to wear a respirator, though few can be induced to make use of these for 
any length of time. In the local treatment the matter of first importance 
is the complete removal of secretions and crusts. These can be softened 
by means of a nasal or postnasal spray of oleum petrolatum album, or more 
simx)ly by having the patient droj) frequently into the nose from ten to 
twenty drops of fluid vaseline. This is carried back hy the air-current, 
and spreads over the nasoi)haryux, if the patient be told to snuff the oil 
back. The thick fluid vaseline stays much longer in contact than the thin 
oleum petrolatum album. After the secretions are softened by the oil 
they must be washed away, and for this pur^Dose the postnasal syringe is 
useful. The objections to it are that it forcibly floods the nasophaiy nx 
with fluid, which is liable to enter the Eustachian tube and middle ear, 
with resulting otitis, and that when the postnasal syringe is used the 
patient is apt to lift his velum so as to shut off much of the nasopharynx 
from contact with the fluid employed. The nasal douche is even more 
dangerous to the ear, and does not wash the vault of the pharynx, where 
most of the secretion lodges. Postnasal sprays have not sufficient force 
to wash away discharges as tough as those found in postnasal catarrh. 
The nasal irrigating tube described in earlier parts of this work is the 



424 DISEASES OF THE NOSE AND NASOPHARYNX. 

most efficient device for cleaning the nasoj^harynx with safety and a 
minimum of discomfort (Fig. 102). The patient easily learns to pass it 
back through the nostril into the nasopharynx, and its minute streams 
have enough force to remove all discharge without endangering the 
middle ear. The instrument is called Freer' s nasal irrigating tube, and 
consists of a straightened haid- rubber Eustachian catheter with three 
small holes one-sixty-fourth of an inch in diameter bored through one 
wall of the tube near its end, while the usual orifice is closed. It can 
be attached to any irrigator or fountain syringe. One of the best 
fluids for a wash is a watery solution of potassium permanganate in 
the strength of one grain to a half-pint of water. The patient should 
be told to breathe through his mouth while irrigating, so that the fluid 
will not run down into the larynx and make him cough. The solu- 
tions used should always be warm. Any alkaline wash — as, for example, 
sodium bicarbonate or equal parts of sodium bicarbonate with sodium 
chloride, one drachm to the pint of water, or Dobell's solution — may be 
used instead. 

In addition to cleansing the nasopharynx by washing, it is usual to 
attempt to influence the chronic inflammation by means of astringent 
or stimulating applications. The amount of success from these will 
depend much on the more or less advanced pathological changes in 
the mucosa. In atroj^hic conditions these remedies will have but a 
palliative effect, and in other cases the results obtained from them are 
sometimes disappointing and not equal to those secured by persistent 
cleansing. The old-time application of a solution of silver nitrate vary- 
ing in strength from ten to sixty grains to the ounce will be found 
beneficial in many cases, and astringent or stimulating sprays, either 
aqueous or oleaginous, are often desirable. When there are enlarged 
follicles without great congestion, and when the parts remain moist, 
great benefit may be deri^'ed from the insufflation, two or three times 
a week, of two or three grains of a powder consisting of berberine 
muriate one part and sugar of milk or acacia two parts. For excessive 
secretion, either here or in the nares, terebeue is beneficial in the pro- 
portion of about ten minims to the ounce of oleum petrolatum album, 
combined or not with other substances, as seems desirable. 

If one desire a decidedly stimulating effect, as in pharyngitis sicca, 
whether due to the atrophic or hj^Dcrtrophic form of catarrh, iodine has 
often a beneficial influence. It can be used in the form of liquor iodinii 
compositus, pure or diluted with one-half water, and is to be applied 
with a swab. It is decidedly painful, and it is well to begin with a weak 
strength, about one part to three of water. 

In isolated catarrh of the bursa pharyngea the secreting furrow may 
be cauterized with silver nitrate fused on a probe, and bridges of tissue 
covering hidden pockets should be divided, together with existing cysts, 
with a small knife, introduced with the rhinoscopic mirror or with 



ACUTE AND CHEOXIC EHIXOPHARYXGITIS. 425 

the finger as a guide. The region of the bursa may subsequently be 
scraped with a curette introduced through the nose while the finger in 
the nasopharynx guides it. 

XASOPHAEYXGEAL DEAFXESS. 

Morbid changes in the nasopharynx, particularly when near the 
orifice of the Eustachian tube, frequently involve the latter and extend to 
the middle ear, affecting the hearing, or else by closure of the Eustachian 
orifice they produce deafness by interfering with the ventilation of the 
tympanic cavity. 

Etiology. — Acute inflammation of the mucous membrane of the naso- 
pharynx, whether idiopathic or occurring with the acute infectious dis- 
eases, such as scarlatina, measles, or influenza, or with secondary syphilis, 
is liable to lead to acute otitis media, either catarrhal or, most often, 
suppurative, with perforation of the drum- membrane. In these cases the 
morbid process extends by continuity up the mucous lining of the Eu- 
stachian tube to the middle ear. The hearing is usually completely 
restored when the otitis media has run its course, but severe inflamma- 
tion may produce total and permanent deafness, with sloughing of the 
drum- membrane, loss of the ossicles, and destruction of the labyrinth. 
In milder cases chronic suj^puration of the middle ear and impaired 
hearing may result. In the same manner chronic catarrhal processes in 
the nasopharynx may extend from the throat to the middle ear, leading 
to chronic otitis media, with resulting sclerosis, fixation of the ossicles, 
and deafness, which may gradually increase until the patient becomes 
very hard of hearing. This is especially true of the atrophic form of 
rhinopharyngitis. Therapeutic attempts, such as passing bougies into 
the Eustachian tube, forcing pus or infectious material into the middle 
ear by the Politzer air-douche or catheter, or water into the tympanic 
cavity h\ a nasal douche or syringe, may cause otitis media of the acute 
and often suppurative variety. 

It should not be forgotten that either acute or chronic middle-ear 
catarrh is at least as often an independent affection as it is the result of 
throat disease, and that it is frequently attributed to this on the post hoc 
ergo propter hoc principle. The impaired hearing accompanying adenoid 
vegetations, however, is a pure type of nasopharyngeal deafness, in which 
the middle ear may be anatomically normal, and hearing impaired merely 
as the result of pressure on the Eustachian tubes by adenoid masses or 
their closure, as these lie against their lumina. This condition stoics the 
entrance of air into the tympanic cavity, so that what remains in it is 
soon absorbed and the drum and ossicles forcibly drawn inward, thus 
crowding the stapes rigidly into the oval window. In some cases this 
is accompanied by a discharge of serum into the tympanic cavity. If 
this last long enough, the rigidity of the ossicles may become chronic 
and some deafness remain permanently, even if the adenoid tissue be 



426 DISEASES OF THE NOSE AND NASOPHARYNX. 

removed ; but it is surprising how long — even months and years — the 
drum can remain drawn inward and yet hearing be perfectly recovered 
in a few daj^s, as soon as ventilation of the middle ear is restored by 
operations removing the adenoid tissue. In some cases the obstacle to 
restoration of hearing is permanent fixation of the stapes in the oval 
window, in others it is contraction of the tensor tympani muscle. 

Swelling of the mucosa of the lumen of the Eustachian tube in post- 
nasal catarrh, and paresis of its opening muscles, the tensor and levator 
palati, may have the same effect in closing it as adenoid vegetations, 
and similarly cause deafness in a purely mechanical manner, without 
any, or but slight, catarrh of the middle ear or damage to its structures ; 
so that, even if these states have lasted for a long time, catheterization 
of the Eustachian tube, with insufflation, may have rapid and gratifying 
results. Unfortunately, these cases are much rarer than those of middle- 
ear catarrh with resulting sclerosis. 

Symjjtorns. — In the acute form the aural complication is often an- 
nounced by intense earache, increase of fever, and perhaps vomiting and 
dizziness. Finally perforation of the drum-membrane occurs, with dis- 
charge of pus and great relief of the symptoms, or the affection subsides 
slowly without suppuration. In the milder acute cases the disease fol- 
lows the latter course. 

In infants the first intimation of complicating inflammation of the 
ear is often a discharge of pus or serum from it, as the symptoms may 
be very mild and the child merely more restless than usual. In other 
eases the symptoms are of a general nature, and do not lead one to 
suspect ear disease. When the disease leads to chronic deafness the 
onset of the symi)toms may be very insidious. Perhaps the first noti- 
fication that the patient has is a slight feeling of fulness in the ear, or 
more often subjective sounds at first not accompanied by deafness. This 
soon sets in, however^ and, getting better or worse by turns, may at 
last reach a high degree. The tinnitus aurium may be distracting. In 
children with deafness from adenoids the parents' complaint is usually 
of seeming lack of attention. In other instances the deafness is first 
noticed in school. 

Diagnosis. — To distinguish between aural affections resulting from 
disease of the nasopharynx and those which exist independently is not 
always possible. Middle-ear catarrh may coexist with disease of the 
nasopharynx, and yet not be caused by it. In other cases an acute rhino- 
pharyngitis may soon pass away, while the middle- ear catarrh persists 
and becomes chronic. 

In little children the diagnosis of the acute variety of otitis accom- 
panying acute rhinopharyngitis is often not made until pus flows from 
the auditory canal. The actions of these patients seldom call attention to 
the ears, because, though some will put their hands to them as if suffering 
from earache, usually all that is noticeable are general symptoms, such 



ACUTE AND CHRONIC RHINOPHARYNGITIS. 427 

as increase of fever, vomiting, great restlessness, and at times convulsions, 
symptoms wliicli do not call attention to the ear. In all acnte colds or 
infections diseases in children the ear should be inspected, whether or not 
there be complaint of earache. In the majority of cases of acute middle- 
ear catarrh in young subjects the drum- membrane will i^resent as a deei:^ 
red surface, so swollen that the malleus and other details are not visible. 
The membrana tympani may be so thickened that it will not bulge ; in 
other and milder cases it will be rounded out by the distending fluid in 
the middle ear. After perforation occurs pus or mucus will be seen in 
the meatus. 

Those cases of deafness accomi)anying adenoid vegetations in many 
instances show merelj" a retracted and at times injected drum-membrane 5 
in others there are the appearances of a catarrhal otitis media. AYhen 
these conditions are found in children, adenoid vegetations should be 
thought of as the probable cause, even if the patients be not mouth- 
breatliers, as adenoid vegetations too small to obstruct breathing may 
cause chronic deafness. This is in most cases due to enlarged Luschka's 
tonsil. 

Prognosis. — Otitis media, whether catarrhal or supi^urative, accom- 
panying acute rhinopharyngitis, in the majority of cases results in per- 
fect recovery, but in a large number chronic suppuration of the tympanic 
cavity remains, while the catarrhal cases maj^ not recover with the rhino- 
pharyngitis causing them, but lead to chronic sclerosis and deafness. 

Treatment. — The suppurative form of otitis media following acute 
rhinopharyngitis requires prom^^t iDaracentesis of the drum-membrane 
as sooi] as there is pus in the tympanic cavity. This usually gives 
prompt relief. 

The details of treatment are more fully set forth in works on dis- 
eases of the ear, and the treatment itself should be carried out by an 
experienced aurist. 



CHAPTER XYL 

HYPERTROPHY OF THE PHARYNGEAL TONSIL. 

Synonymes. — Hypertrophy of Luschka's tonsil, adenoid growths in the vault 
of the pharynx. 

In^ 1655 Schneider discovered the pharyngeal tonsil, but Luschka 
first gave it its name in 1868. The enlargements of this organ have 
such an important bearing on the health of the individual that their 
description forms one of the most important chapters in laryngology. 
Deafness, deformities of the chest and of the upper jaw, displacement 
of teeth, interference with speech, and mouth- breathing, with its train 
of injurious consequences, are all symptoms of the disease. Fortunately, 
its treatment is so satisfactory that in most cases one can expect to 
bring about complete recovery unless the disease has been allowed to 
become chronic. 

Etiology. — One or repeated attacks of rhinopharyngitis with acute 
swelling and inflammation of Luschka' s tonsil are the commonest causes 
of adenoid vegetations. In some cases, after an inflammation of the pha- 
ryngeal tonsil has passed off, even if it be a first attack, the tonsil, hith- 
erto normal in size, remains permanently large, so that the symptoms of 
adenoid vegetations set in suddenly. Frequently the pharyngeal tonsil 
becomes permanently enlarged only after it has repeatedly been the seat 
of inflammation. Luschka' s tonsil, like the faucial tonsils, is merely a 
lymphatic gland, and it responds to infectious agents by inflammation, 
rarely by abscess, and often by chronic hyperplasia, as do other lymph- 
glands. Chronic hyperplasia predisposes decidedly to tubercular infec- 
tion of lymphoid tissue, whether in Luschka' s tonsil or a cervical or 
inguinal lymphatic gland, so that tubercular infection of adenoid vegeta- 
tions may be secondary to the enlargement of Luschka' s tonsil, or the 
tubercle bacillus may cause its enlargement primarily. The former con- 
dition is probably the more frequent. 

Xext to acute infections of the pharyngeal tonsil, chronic nasal or 
postnasal catarrhs, especially the purulent ones of childhood, are liable 
to induce its hypertrophy, as similar states — for instance, chronic eczema 
— may lead to enlargement of lymphatic glands elsewhere. In other cases 
the pharyngeal tonsil gradually enlarges by means of a chronically in- 
creasing hyperplasia, without local source of infection. Similar con- 
ditions are seen in the lymphatic glands in other parts of the body. 

Adenoid vegetations constitute a disease of childhood. The con- 
dition may persist into adult life, but does not originate after puberty, 
as normally the pharyngeal tonsil atrophies at this period, so that even 
428 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 429 

adenoid vegetations may disappear by absorption at this time. They 
are seldom seen before the second year, and do not proi)erly constitute 
a disease of infancj', but begin to be common after the second year and 
up to the twelfth and fifteenth. Enlargement of Luschka's tonsil may, 
however, occur as early as the first month of life, and is not rare up to 
the twentieth year. 

Adenoid vegetations are among the commoner diseases, — in fact, are 
found in about the same proportion of cases that enlarged tonsils are. 
In most cases enlargements of the faucial and pharyngeal tonsils coex- 
ist, and it is more usual to find the pharyngeal tonsil hypertrophied and 
the faucial ones normal or but slightly changed than to find a nor- 
mal nasopharynx with enlarged tonsils. It is a common practice to 
remove the faucial tonsils and ignore the more injurious pharyngeal one, 
— a i^ractice giving the i:)atient but slight or no relief, so far as breathing 
is concerned, and injuring the reputation of the operator. As they are 
among the chief causes of acute inflammations of the liharjmgeal tonsil, 
acute infectious diseases, especially scarlatina, diphtheria, measles, and 
whooi^ing-cough. often leave adenoid vegetations as a sequel. 

Climate has a moderate influence as a predisposing cause, and adenoid 
vegetations are common in regions with extremes of temxDerature, but 
the disease exists in all i^arts of the world. The scrofulous diathesis has 
been assigned as a cause, but many observers now think that it is the 
result of chronic rhino pharjmgitis with adenoid hypertropliy rather than 
a cause of these conditions, and that the first influence i)roducing the 
scrofulous state is chronic catarrh of the nasal cavity and i^ostnasal space, 
leading to the eczema of the uj^per lip and nostrils and the enlargement 
of the lymphatic glands and pharyngeal tonsil common to scrofulous 
children. Xevertheless, the term scrofulous diathesis has its justification, 
as the conditions described chiefly occur only in children with little 
resistance to infectious catarrhal affections of the u^^per air-i^assages and 
who are j)rone to enlargement of the lymphatic structures, with secondarj^ 
tubercular infection in consequence. The influence of syphilis in -pvo- 
ducing adenoid vegetations is uncertain. They are common to all races 
of men. 

Pailwlogy. — Xormally, adenoid or, as it is also called, lym^^hoid tissue 
is found in abundance throughout the nasal and pharyngeal mucosa, but 
in certain regions it shows a tendency to accumulate in masses and form 
what is called a tonsil. Thus there are the lingual tonsil, the faucial 
tonsils, and the one under consideration, — the pharyngeal tonsil. This 
is really a structure of childhood and early youth, as after these periods 
there is rarely enough adenoid substance left to create a tonsil. As a 
rule, the accumulation of adenoid tissue in the j)haryngeal vault extends 
from the ui^i^er border of the choanse to the tubercle of the atlas, and 
laterally from one Eustachian tube to the other. It does not end 
abruptly at its borders, but merges insensibly into the surrounding 



430 DISEASES OF THE NOSE AND NASOPHARYNX. 

mucosa. At its most prominent portion, just back of the choanse, the 
lymphoid tissue is divided into two portions by a dee^D vertical antero- 
posterior fissure, the recessus pharyngeus medius. On either side of this 
are from three to four i^arallel fissures which enter the adenoid substance 
and often branch there into minor ones, so that a single fissure seen on 
the pharyngeal vault usually leads into a complicated system of recesses 
in the adenoid mass. These chief fissures may be crossed by transverse 
ones which subdivide the i^haryngeal tonsil into smaller areas. The surface 
of the pharyngeal tonsil thus acquires an appearance like that of minia- 
ture cerebral convolutions. The description of the normal Luschka's 
tonsil leads to an understanding of the appearances of diseased ones. A 
number of these retain the general shape of the normal Luschka's tonsil, 

Fig. 163. 



.^■^, 





r 


^^y^ 




/ 


/ 




\ 
\ 



Khinoscopic image of an enlarged Luschka's tonsil. (Heymann.) 

but exceed it greatly in size, jutting into the nasopharynx from its roof 
in the shape of a well-defined lump. This variety of enlarged pharyn- 
geal tonsil is generally of firm consistency, in some cases almost fibrous 
in character. It is occasionally seen in young adults, but occurs fre- 
quently in children. 

In another grouj) of cases the enlarged pharyngeal tonsil does not 
form a well-defined, firm tumor, but is found in the shape of soft out- 
growths which depend from the pharyngeal vault like polypi. To these 
the name of vegetations is well applied. This variety of adenoid vege- 
tations is generally soft and friable, and is apt to occur with those 
pharyngeal tonsils which are subdivided by numerous transverse fissures 
and possess little connective tissue, so that from lack of firmness the 
separate parts yield readily to the force of gravity and present in berry- 



HYPERTROPHY OF THE PHARYXGEAL TONSIL. 



431 



Fig. 164. 



like or i3olypoid shapes. In rare instances softened, cheesy deposits 
of tubercular origin are found in the adenoid masses, but almost invari- 
ably these present the naked-eye appearances of healthy lymphoid tissue 
of a light pink or bluish color and semi- translucent nature. Though the 
above two types are those generally found, the form and position of the 
adenoid masses show great variations. Thus there may exist a firm, 
smooth outgrowth like an arch placed between the Eustachian orifices 
and compressing them, while it does not descend far enough to interfere 
with nasal breathing. In other cases the firm variety of enlarged pharyn- 
geal tonsil is seated low down on the posterior i^haryngeal wall, extend- 
ing a short distance upward from the level of the velum, while the 
pharyngeal vault is comparatively free. The soft variety with depend- 
ent vegetations has a strong tendency to invade the posterior nares, so 
that i>olypoid masses of adenoid tissue grow within the iDOsterior ends of 
the nasal fossae and obstruct breathing. 
In many cases the adenoid tissue has a 
predilection for the lateral regions of the 
nasopharynx, blocking the Eustachian 
tubes and fossae of Eosenmiiller. A small 
adenoid mass may be so situated as to 
interfere with the function of the Eu- 
stachian tube, and deafness may occur 
without impaired breathing through the 
nose. 

Histologically, the conditions are the 
same as are found in the normal jDharyn- 
geal tonsil, — viz., lymphoid elements in 

hxrge quantity'. The surface of the adenoid growth is for the greater part 
covered with ciliated epithelium ; in places pavement or cuboid epithe- 
lium is found. Beneath the ei:)ithelial layer lies the basement membrane, 
and below this is a more or less dense connective-tissue reticulum closely 
packed with round cells and containing numerous large lymph-follicles 
and the ducts of the mucous glands. The acini of the latter lie in the 
submucous layer of the connective tissue below the layer of adenoid 
tissue. Below the snbmucous region there is the dense, firm connective 
tissue of the basilar fibrocartilage of the pharyngeal vault. 

Miliary tubercles, tubercular, softened, cheesy masses with bacilli, and 
giant cells have been found in the pharyngeal tonsil, and there is no 
doubt that its tubercular infection is far more frequent than is supposed, 
though still rather rare. Considering the importance assigned at present 
to the entrance of tubercular infection into the organism through the 
lym^Dhatic structures of the fauces and pharynx, and its penetration of 
the lymph-glands of the neck and thorax through these channels, the 
possibility of adenoid vegetations being tubercular, and a possible source 
of pulmonary phthisis or tubercular meningitis at some future time, 




Adenoid 



vegetations hiding the upper 
part of the choante. 



432 DISEASES OF THE NOSE AND NASOPHARYNX. 

is one more important reason for their radical removal and an argu- 
ment against leaving any portion of them behind, as is apt to occur 
with certain popular and imperfect modes of operation. It is asserted 
that more cases of pulmonary tuberculosis are due to entrance of the 
bacilli through the pharyngeal or faucial tonsils than to their invasion 
of the body by inhalation into the lungs, and that the tubercle bacillus 
penetrating the lymph-glands in childhood lies dormant until the usual 
time for the appearance of phthisis. Dieulafoy produced tuberculosis 
seven times in guinea-pigs inoculated with portions of thirty-five extir- 
pated pharyngeal tonsils. 

Pathological conditions accompanying enlargement of the pharyn- 
geal tonsil are seen in the upper jaw, the thorax, and the nose. The 
upper jaw is apt to present what is known as the high-arched apj^ear- 
ance, the hard palate being unusually concave and reaching far up- 
ward, while the jaw is narrow from side to side, and the alveolar arch 
ends in a Y in front instead of an even curve. This throws the teeth out 
of line, so that, for lack of room, the central incisors form a projecting 
angle and are apt to cross each other. The edges of the lateral incisors 
are not placed transverselj", but antero-i^osteriorly, while the canines 
appear in a plane above the incisor teeth. The teeth growing in the 
pars incisiva of the upper jaw project beyond the incisors of the lower 
jaw to an abnormal extent. The shape of the latter remains normal. 
These changes are noticeable in the first set of teeth, but much more so 
during second dentition. The incisor teeth of both the first and second 
set are prone to decay early. Children of from twelve to fourteen 
years of age have been seen with their second incisors entirely decayed. 
It must not be supposed that these changes in the upper jaw are in- 
variable and exist in all cases of adenoid v^egetations ; there must be some 
individual predisposition, as many people with this affection have nor- 
mally shaped upper jaws and perfect teeth. The reason for the deformity 
is lack of development of the nasal cavity. Adults are seen whose nasal 
fossae, though normal in shape, have remained more or less infantile in 
size as the result of adenoid vegetations in childhood. These cases have 
the high-arched palate, and cannot obtain enough air for comfortable 
nasal respiration through their small but normally formed nares. This 
condition is irremediable, unless respiration be made free by resection 
of one or more of the turbinated bones. 

The nostrils are sometimes found narrowed as a result of disuse of the 
muscles of the alee nasi, but the most common nasal deformity due to the 
presence of adenoids is narrowness of the posterior portion of the nasal 
fossae. Their anterior portion is generally normally roomy, but in the 
back of the nose the turbinals approach close to the septum, while at the 
same time a fold of mucous membrane often closes the upper arch of the 
choanse. This narrowness of the bony and soft parts forming the 
choanse is found in quite young children with enlarged pharyngeal tonsil, 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 433 

and forms an important feature in the operation for its removal, as, if 
these deformities be not corrected at the time of operation, the mere 
removal of the adenoid tissue in the nasoj^harynx will not give any, or 
but imperfect, relief. 

Deviations of the septum are often found comi)licating enlarged 
pharyngeal tonsil, especially in those nearing or past puberty ; but in 
little children one finds the septum straight and the nasal fossae clear, ex- 
cept at their posterior portion. The thorax, though in most cases normal 
in shape, may show changes due to the nasal obstruction and difficult 
juouth-breathiug. Though in the daytime the mouth forms a widely 
open channel for air, unless enlarged tonsils be a complication, at night, 
in sleep, the tongue is apt to sink backward and obstruct the larjmx, and 
if this condition be complicated by enlarged fiiucial tonsils the obstruc- 
tion to brenthing may be very great. Children with this combination of 
enlarged pharyngeal and faucial tonsils breathe in a most alarming way 
during narcosis, and asphyxia seems imminent at any moment. In some 
cases the obstruction to breathing is quite enough to deform the thorax 
when continued for long periods. The usual tyi^e of chest resulting is 
the one called emphysematous. In this the upi^er part of the thorax is 
distended, while the lower parts do not expand properly ; in other cases 
the children are flat-chested or have pigeon-breast. Whether flat chest, 
deformities of the spinal column, lordosis, kyphosis, and scoliosis are, as 
alleged, due to the adenoid disease or the result of school-benches and 
imperfect physical development is a question. 

Si/m2)toms. — The most striking symptom of adenoid vegetations is the 
obstruction to nasal respiration. In the great majority of mouth-breathing 
children such growths, and nothing else, cause this symptoDi. So fre- 
quently is this the case that some rhinologists attempt to diagnose the 
existence of adenoid vegetations from this symptom alone ; but, though 
other causes of nasal obstruction in children are rare, they occur with 
sufficient frequency to need consideration. Thus, a number of mouth- 
breathing children will be met in any of the larger clinics whose defective 
respiration is due to hypertrophic rhinitis or nasal mucous polypi, while 
no trace of an enlarged Luschka's tonsil exists. 

The nasal obstruction in enlarged Luschka's tonsil is in most cases 
lasting and unvarying, but in a number of them is subject to exacerba- 
tions and remissions. These remissions are apt to lead the parents and 
even the j)hysician to think that the child is outgrowing its affection. In 
the milder cases mouth -breathing may occur only during sleep, while in 
the daytime the child has nasal respiration. In the severer cases the 
mouth is held open in the daytime, and the child acquires the i)eculiar 
stupid and listless expression known as the adenoid face, — an expression 
which is, however, not limited to adenoids, but is found with any nasal 
obstruction in children. 

The second striking symptom due to adenoids is snoring. It may 

28 



434 DISEASES OF THE NOSE AND NASOPHARYNX. 

attract more attention than the mouth -breathing, and be loud enough 
to annoy others and greatly distress the parents. It is especially loud if 
the faucial tonsils be enlarged at the same time. Under these conditions 
there is not only obstructed nasal breathing due to the adenoid vegeta- 
tions, but the narrowing of the fauces by the enlarged tonsils and the 
dropping back of the tongue on the larynx during sleep cause dyspnoea 
that is painful to witness, and whose recurrence on successive nights 
alarms the parents. The snoring is probably caused by vibrations of the 
soft palate and perhaps of the epiglottis in the air-current. The op- 
pressed breathing causes nightmare, so that these children are subject 
to nocturnal terrors. The reason why the air-current through the nose 
is so much more obstructed at night than in the daytime is found in the 
fact that mucus collects in the inferior meatus, the only nasal passage 
left open by the adenoids, and this condition and swelling of the posterior 
ends of the inferior turbinals due to venous congestion are apt to be super- 
added to the adenoid difficulty. 

The third important symptom of adenoids is deafness. The occur- 
rence or absence of this depends much on the shape and location of the 
growths. Acute inflammation of Luschka's tonsil may, as has been 
shown, lead to catarrhal or suppurative otitis media by direct extension 
of the accompanying acute rliinopharyngitis. AVhen this occurs with 
an already enlarged pharyngeal tonsil, otitis media is even more likely 
to happen, so that many children with adenoid vegetations have recur- 
rent attacks of running ears. The usual effect of adenoid vegetations on 
the auditory apparatus is, however, merely mechanical, and is due to 
their obstructing the Eustachian orifice. They may cause this by filling 
up the fossa of Eosenmiiller, and creating pressure from above and be- 
hind on the Eustachian i)rominences, thus preventing the proper opening 
of the tubal orifices for ventilation of the middle ear, or portions of the 
vegetations may lie directly against the openings of the tubes and have the 
same effect. This often leads to catarrhal otitis, though more frequently 
it merely deprives the middle ear of its air-supply ; hence removal of the 
adenoids restores the hearing in a few days. When the deafness has 
lasted a long time, recovery is not usually to be expected, though decided 
improvement may result. In some cases deafness is the only symptom of 
enlarged pharyngeal tonsil, as this may not be large enough materially to 
obstruct breathing, especially if the nares be more than usually roomy. 
When the adenoid vegetations are extensive enough to close the nasal 
fossse completely (a very rare condition), aspiration of air from the mid- 
dle ear must occur as a result of the vacuum x3roduced in the nasopharynx 
during swallowing with a totally obstructed nose. The senses of taste 
and smell are lessened or arrested by adenoid obstruction. 

A fourth important symptom of adenoid vegetations is change of 
voice. This applies especially to the pronunciation of those consonants 
requiring an open nasal and nasopharyngeal passage, m, n, and ng. 



HYPERTROPHY OF THE PHARYXGEAL TONSIL. 435 

Children with adenoids sufficient to shnt off the nasal cavity to a great 
extent from the nasopharynx will pronounce these Z>, d, t. If the nose 
be occluded at its anterior end, m and 71 can still be pronounced, as the 
nasal chambers act as resonators. The adenoid voice has, therefore, a 
peculiar dead, non-resonant quality differing from that due to obstruction 
of the anterior parts of the nose, which gives to the voice a nasal twang. 

Among the comj)lications of adenoid A^egetations the deformities of 
the upper jaw. thorax, and nasal passages have been described under 
pathology. Another moderately frequent complication is nasal catarrh. 
In most children inspection of the nasal foss?e shows these to be normal 
or even rooDiy, while the turbinals are not swollen. In another type of 
child with adenoid vegetations there are pronounced chronic nasal 
catarrh, swelling of the turbinals, especially at their j^osterior ends, and 
the nasal fossre are filled with muco-pus or crusts. These children are apt 
to present a scrofulous appearance. Adenoid vegetations are never asso- 
ciated with atrophic rhinitis, but the turbinals are often abnormally small 
and undeveloped. Cleft palate is frequently accompanied by adenoid 
vegetations. Bronchial asthma has been noticed as associated with them 
and disappearing after their removal. This can be understood when 
one considers the irritation of the larynx, trachea, and bronchi resulting 
from mouth-breathing. — an irritation which may result in laryngitis, 
tracheitis, and bronchitis. Pseudo-croup, or laryngismus stridulus, is 
a rare symptom of adenoid vegetations, and may result from the direct 
irritation of the larynx from mouth-breathing or from mucus which flows 
down into the larynx from the nasopharynx at night. The voice obstruc- 
tion may result in paresis of the laryngeal muscles and hoarseness, on 
account of the greater strain thrown on the vocal cords during phonation 
in the effort to overcome the obstacle to sound caused by the adenoid ob- 
struction. Children and adults with enlarged pharyngeal tonsil may be 
afflicted with a nervous tickling cough due to reflex irritation excited by 
its presence in the nasopharynx. Headache is a not unusual symptom, 
especiallj^ in older children and adults with such tonsillar hypertrophy, 
and the headaches complained of so often bj^ school-children are some- 
times explained by the presence of adenoid vegetations. The seat of the 
pain is indefinite, or it may be occipital, frontal, or temporal. 

It is a singular fact that removal of adenoid vegetations has in some 
cases put a stop to enuresis nocturna, and the same result has followed 
the removal of other nasal obstructions. Among the nervous symptoms 
occasionally relieved by the adenoid operation is stuttering. Aprosexia, 
or inability to concentrate the mind, and mental dulness have been 
attributed to adenoid vegetations, and certainly mental improvement in 
dull children has usually been observed to follow removal of enlarged 
Luschka's tonsil. This may be due merely to the remarkable gain in 
general health that often follows this, as it does the operation of ton- 
sillotomy, — an improvement explained in various ways, but still rather 



436 DISEASES OF THE XOSE AND NASOPHARYNX. 

incomprehensible. Though many children with adenoid vegetations look 
blooming and healthy and are not retarded in their growth, the excep- 
tions to this satisfactory state are so frequent that the physician is forced 
to attribute to adenoid vegetations the anaemic, ill- nourished condition 
of many of the patients, and it is a frequently observed fact that, after 
removal of the adenoids, children who have up to this time remained 
undersized begin to grow rapidly and even abnormally fast. 

Inspection is more often possible than would be supposed, but pos- 
terior rhinoscopy generally needs to be aided by the application of a five 
per cent, cocaine solution to the fauces, and especially to the posterior 
wall of the pharynx, against which the rhinoscopic mirror impinges. 
When there are enlarged tonsils posterior rhinoscopy is very often im- 
possible. In many cases the reflexes of the oropharynx in children with 
adenoid vegetations seem remarkably deficient, which is perhaps due 
to blunting of the sensitiveness of the mucosa on account of mouth- 
breathing. This condition is an aid to examination. When posterior 
rhinoscopy is possible, the pharyngeal tonsil i)resents the appearances 
described under pathology. The color of the enlarged pharyngeal tonsil 
is light pink, and at times it looks translucent and cedeinatous, at others 
firm and solid. The foreshortening of the rhinoscopic image makes the 
antero-posterior folds between the fissures of the tonsil seem mere knob- 
like prominences. Beyond the depending pharyngeal tonsil one sees 
more or less of the x^osterior nares, often merely the upper arched border 
of the choanse being hidden. In the more marked cases the middle, and 
in i^ronounced ones the lower, turbinal is hidden from view, and all that 
is seen is the bottom of the lower meatus and a little of the lower part 
of the vomer, or i^ossibly nothing of the choanae. These latter cases 
present at first a confusing aspect, as the usual landmarks of the post- 
nasal space are hidden. In cases of deafness in children it is very hard 
to determine just how much injury to hearing a small adenoid mass is 
causing by pressing on the Eustachian tubes, and inspection may not 
make this point clear enough to be certain whether the adenoid growth 
is occluding the Eustachian orifices or merely happens to coexist with 
catarrhal otitis media without causing or aggravating it. In these cases 
removal of the enlarged pharyngeal tonsil must be advised, so as to 
eliminate its jDOSsibly bad influence on the hearing. If no improvement 
result, the parents are apt to feel dissatisfied unless they have been 
warned that an adenoid operation does not invariably imjorove or remove 
the deafness. Inspection may show the nasopharynx to be full of mucus or 
iiiuco-pus, which can be seen flowing down the posterior pharyngeal wall. 
This condition is by no means so common as the literature of the sub- 
ject would lead one to suppose, and in children with adenoid vegetations 
the mucous membrane of the nose and nasopharynx is more frequently 
in a healthy state than in a condition of chronic catarrh, so that posterior 
rhinoscopy generally shows the walls of the nasopharynx and the sur- 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 437 

face of the adenoid vegetations free from secretion and natural in color. 
The surface of the removed pharyngeal tonsil is also almost invariably 
found free from adherent secretions, and these are very seldom discovered 
on the finger when it is withdrawn after an examination of the naso- 
pharynx. 

In little children, refractory ones, and those whose velum is too close 
to the posterior pharyngeal wall, inspection of the nasopharynx is not 
possible, and here its digital exploration is required. It has been stated 
that this is brutal and needless. If the symptoms of adenoid vegetations 
were such that they would unerringly announce their presence, digital 
examination might be unnecessary ; but as various nasal obstructions not 
visible from in front, such as nasal mucous polypi in the choanse, or swell- 
ing of the posterior ends of the turbinals, may block the nose at its pos- 
terior part, and cause symptoms similar to those of adenoids, digital 
exploration is needful in order to make a differential diagnosis and de- 
termine tlie method of operation. Digital exploration is neither very 
distressing nor painful if the oropharynx and nasopharynx of the child 
be first si:)rayed with a slight quantity of a solution of cocaine. Chil- 
dren do not usually object to the introduction of the gag, and passing a 
finger into the mouth does not frighten them. In place of the gag the 
thumb of the disengaged hand can be used to push tlie cheek between 
the child's teeth so that it cannot close its mouth without biting itself; 
but children do not usually try to bite. The method of examination is 
described in the preliminary part of this article. The finger should first 
feel for the septum uarium and the firm prominences of the Eustachian 
orifices 5 then the vault and rear wall of the nasopharynx should be 
palpated from the septum back. Some adenoids present as a firm, fleshy 
tumor between the Eustachian tubes, and are easily felt. The soft va- 
riety, however, is hard to feel, and slips away from the finger, so that 
one may imagine that the nasoj)harynx is free from adenoid growths 
unless it be palpated very gently. In this case the soft, cushion-like 
feeling given by the vegetations is very different from the firm, bony 
resistance offered by the pharyngeal vault, which is so characteristically 
hard that when touched it is known at once that there are no adenoids 
l^resent. It is a good rule never to withdraw the finger from the naso- 
pharynx before being sure that everything has been carefully palpated. 
The tendency is to relieve the child of the possible distress, and to take 
the finger out before a conclusion is reached. The examiner must decide 
not only whether adenoid vegetations are present at all, but whether 
they are in sufficient quantity to need operative removal. When the 
finger is withdrawn there will be blood upon it if there be adenoid vege- 
tations, as they bleed when touched. 

Diagnosis. — As any chronic affection causing stoppage of the nasal 
passages may cause symptoms not differing materially from those of 
adenoid vegetations, examination of the patient by anterior and posterior 



438 DISEASES OF THE KOSE AND NASOPHARYNX. 

rhinoscopy and, if needed, palpation of the nasopharynx are absolutely 
necessary to establish a diagnosis. If these means be employed an error 
is unlikel}^, whereas those who attempt to recognize the disease merely 
from the symptoms are liable to mistake certain other and rarer affections 
for the ailment. 

^N'asal mucous polypi, though rarely, do occur in children. If in the 
nasal fossae, anterior rhinoscopy will discover them. It is only when 
they develop in the posterior part of the nares and grow into the post- 
nasal space that a question can arise in the diagnosis, as, when of large 
size, they may nearly fill the nasopharynx. If i)Osterior rhinoscopy be 
possible, the grayish translucent polyi)us with its glassy surface cannot 
be mistaken for adenoid vegetations, especially as these hang from the 
pharyngeal vault, while the polypus rests on the soft palate. If the 
diagnosis must be made by palpation, the mobility of the polypus will 
serve to distinguish it ; but if it be very large, so as to fill the postnasal 
space, the nature of the growth may become clear only after it has been 
removed. As both the polypus and adenoid vegetations can be brought 
away by the Lowenberg forceps, a failure to distinguish the two affec- 
tions is not of great moment. Fibroid tumors are much harder than 
the hypertrophied glandular tissue ; they are frequently attended by 
severe epistaxis, and upon being touched bleed easily and profusely. 
They are usually of a bright red color with blood-vessels api)arent ui:)on 
the surface, and, when large, cause distortion of the neighboring parts. 
None of these signs is observed in hypertrophy of the pharyngeal 
tonsil. 

Prognosis. — Probably in seventy -five per cent, of the cases the gland, 
if left to itself, would atrophy at about the twelfth or fourteenth year ; 
but in the mean time irreparable harm to the ear, the voice, or the gen- 
eral health may result. In the remaining cases the gland gradually 
diminishes in size, and disappears before middle life. It is important 
that operative measures be not too long delayed, as deformities of the 
upper jaw or thorax will continue to progress, and hearing perhaps be- 
come permanently damaged if relief be not prompt. As stated above, 
though the adenoid operation will aid in the removal of deafness, too 
favorable a prognosis will cause disappointment in some cases. In re- 
gard to the disappearance of moath-breathing, j)redictions must also be 
guarded. In many cases nasal respiration is resumed in a day or two 5 
in a large number, however, the mouth-breathing habit is so firmly 
established that even with free nasal passages the child goes about with 
its mouth open. Such patients are sometimes brought back to the 
physician with the remark that the operation was not complete, when 
anterior and posterior rhinoscopy will show the nasal fossae and naso- 
pharynx entirely free from obstruction. In this case it is hard to con- 
vince the parents that the mouth-breathing is merely a bad habit. In 
other cases intumescent rhinitis may cause it to persist, or a septal 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 439 

deflection may have the same effect. AVhen the operation for removal 
of adenoid vegetations is not completed through the nasal passages in 
the manner to be described, narrowing of the choanae or the presence 
of adenoid masses within the posterior parts of the nasal fossse may con- 
tinue the obstruction to nasal respiration. After thorough removal of 
the adenoid tissue it does not reappear, but after the operation with the 
ring-kiiife, the most po^^ular method in use to-day, returns of the adenoid 
vegetations are frequent^ as their superficial i^arts are taken away and 
deeper portions often left behind. 

Treatment. — The principal surgical measures in vogue at present are 
removal of the adenoid tissue hy the Gottstein ring-knife or similar 
appliances, or by the use of postnasal forceps with cutting beak, of 
which the Lowenberg forceps is a tyjoe. 

Bing-Ktiife Operation. — The operation with the ring-knife is most often 
practised, and the rapidity and ease with which it enables the surgeon 
to operate have given it an undeserved x)opnlarity. Though there are 
many modifications of the ring-knife, that of Gottstein is undoubtedly 
employed more than any other. The blade is attached at about a right 
angle to the end of the shank, which is so curved that the ring-shaped 

Fig. 1G5. 




Gottstein's ring-knife. 

blade can be introduced into the pharj^ngeal vault, where it shaves off 
the growths j^resent there as it is withdrawn. Emil Mayer {New York 
Medical Eccord, vol. xliv. p. 415) has designed a pharyngeal curette that 
is more useful for clearing adenoid tissue from the j^osterior pharyngeal 
wall and the vault of the pharynx than any curette heretofore devised. 
The operation is generally done without narcosis. The patient^ if a 
child, is held on the lap of an assistant, who is seated in a chair and 
seizes its body and arms with one arm, which presses the child's back 
against his chest, while with the disengaged hand he bends back its head 
firmly against his breast. The operator, with the guidance of a head- 
mirror, presses down the tongue with a tongue-depressor, and passes the 
ring-knife up behind the velum as high in the nasopharynx and as far 
forward as possible, while the shank of the instrument presses the soft 
palate towards the front. The knife is then drawn backward and down- 
ward in the median line, while it is firmly pressed against the pharyn- 
geal vault. The knife can then be returned to the region just back of 
the choanse and s^ept backward along the lateral parts of the vault of 
the pharynx, so as to clear these regions of portions of the growth. 
After the first cut has been made tlie detached pharyngeal tonsil may 



440 DISEASES OF THE NOSE AND NASOPHARYNX. 

often be seen to sink down into tlie oropharynx, whence it may be 
retched out or pulled out by the ring-knife. It may also be swallowed 
or lodge in the lateral parts of the nasopharynx and appear later, per- 
haps through the nostrils. As soon as the knife is withdrawn the child's 
head should be bent over a basin to catch the freely flowing blood. 
The hemorrhage generally soon ceases. If the bleeding continue it may 
be necessary to inject cold water into the nasopharynx, and in rare cases 
this region has to be plugged. Preliminary applications of cocaine are 
useful, but not very effective. When children are very unruly and so 
large that they cannot be firmly held against their will, general narcosis 
becomes necessary. The child is ausesthetized in the recumbent position 
to the degree of half narcosis, after which it is placed in the assistant's 
lap and the operation proceeded with as described. 

The ring-knife operation is rapidly done, easy because mechanical 
in nature, usually requires no anaesthetics, and for these reasons has 
become very popular, especially with those lacking experience in rhi- 
nology. The objections to this method are far more numerous than its 
advantages. As usually performed, without anaesthesia, it is cruel. The 
nasopharynx is extremely sensitive, as is obvious to any one who con- 
siders its nerve-supply, and the i^ain caused by the oxDcration is extreme. 
Local anaesthesia does not prevent this, as it cannot act upon the tissues 
at the depth to which the ring-knife penetrates. The distress and 
nervous shock due to terror are not matters of small moment, and may 
leave the child timid for years. The ring-knife operation is liable to 
be followed by severe, prolonged, and even fatal hemorrhage, though 
this is much rarer than the bleedings which follow tonsillotomies. The 
reasons for the serious hemorrhage are the clean-cut nature of the in- 
cision made by the ring-knife and the fact that the lateral walls of the 
nasopharynx and the Eustachian orifices, with their rich blood-supply, 
are liable to be wounded in the blind gropings with an instrument 
which may fit the nasopharynx for which it was designed, but can- 
not possibly adjust itself to the many sha]3es of postnasal cavities en- 
countered. This lack of fitness for varying conditions is common to 
most mechanical modes of operation. If the operator confine himself 
strictly to the median line, the result is apt to be imperfect ; if an attempt 
be made at thoroughness, so that the lateral portions of the pharyngeal 
vault are scraped, there is danger of causing severe hemorrhage. The 
tubal prominences are especially vascular, and if projecting are liable to 
be wounded ; the extent to which they protrude varies greatly in dif- 
ferent individuals. The ring- knife operation is not thorough ; it ignores 
the adenoid masses so frequent in the posterior nares and the narrowing 
of the choanae so often found, and is not adapted to clearing the poste- 
rior pharyngeal wall of adenoid tissue, though this is a region in which 
its largest mass may be situated. The instrument is also badly fitted for 
removal of masses growing about the tubal orifices. It does not cut off 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 441 

the adenoid tissue to a sufficient depth, so that the lymphoid tissue left 
behind has a tendency to sprout and replace the pharyngeal tonsil, a 
disposition to proliferation shared by all diseased lymx^hoid tissue. 

It is not a matter of indifference whether or not a return occurs. The 
pain of the operation must be endured again, the child's terror is in- 
tensified by its recollection of the first operation, and the parents, dis- 
appointed and scei)tical, will wait until the evil results of a renewal of 
the growth have reached a high degree before they will consent to a 
second operation ; meanwhile great damage may have been done to the 
hearing or result from the mouth-breathing. It is not right to run the 
risk of having to perform a second operation if the first can be so done 
that a relapse cannot occur. 

Mouth-breathing may persist after the operation with the ring-knife, 
as after all pharyngeal tonsil oj^erations, even if the adenoid tissue be 
comi^letely removed, but is more commonly due to portions of this tissue 
left behind after operation and located in the posterior nares, — jDortions 
which could not be included in the sweep of the knife, — or else the 
mouth-breathing is caused bj' narrowing of the choan?e. It is one of 
the chief faults of the ring-knife operation that it can only clear the 
pharyngeal vault and cannot reach the adenoid tissue located elsewhere. 

The advocates of the ring-knife operation regard the absence of gen- 
eral anaesthesia which it permits as one of its great advantages, and 
justly so. This argument should, however, not have enough weight to 
induce the rejection of a thorough operation for one liable to be imperfect. 
The advantages of anaesthesia are absence of the severe pain caused by 
operations in the nasopharynx and of the deleterious nervous shock due 
to terror and the sight of blood. Anaesthesia enables a surgeon to perform 
the operation in a deliberate and thorough manner instead of in a hasty 
and incomplete one. Half narcosis is objectionable 5 therefore the anaes- 
thesia should be profound enough to abolish the pharyngeal reflexes. 
This is obvious to any one who palpates the nasopharynx while the patient 
is under an anaesthetic. The contractions of the pharyngeal muscles, by 
causing folds and ridges, make the surgeon uncertain in a conscious child 
as to what he feels. These do not occur during insensibility, and one 
can accurately determine the location and size of adenoid masses that 
could hardly be felt in a struggling child. Ether or chloroform is the 
anaesthetic to be preferred. The most rapid and satisfactory anaesthesias 
are generallj' obtained with chloroform, but some children more readily 
yield to ether. The latter is the safer, as a considerable number of 
deaths from chloroform anaesthesia during adenoid operations are re- 
ported, and children with their respiratory passages choked with en- 
larged pharjaigeal and faucial tonsils are especially bad subjects for 
general anaesthesia. The objections to ether are the difficulty of abol- 
ishing the pharyngeal reflex sufficiently to stop retching, which is very 
embarrassing to the operator, and the increase of the secretions in the 



442 



DISEASES OF THE NOSE AND NASOPHARYNX. 



throat caused by this ansesthetic. When there are large tonsils and 
breathing is greatly obstructed, it is better to use ether ; when oral 
breathing is free, chloroform is preferable. Whichever anaesthetic is used, 
the child must be watched with unusual care, and its breathing should 
be under constant observation. If there be cyanosis the anaesthetic must 
be promptly suspended. The most satisfactory operation is that with 



Fig. 166. 




Mackenzie's modification of Lowenberg's forceps. 

the Lowenberg forcei^s, or preferably Mackenzie's modification. Neces- 
sary for its performance are a mouth-gag, preferably Allingham's, a i3air 
of large- and one of small-bladed Lowenberg force]3S, and an Ingals nasal 
bone-forceps, for passage through the nares. The distance from the end 
of the cutting edge of the Lowenberg forceps to the angle in the shank 
of the blades is one and one-half inches. The patient is placed on his 
left side, close to the edge of the table, so that the left arm, which is 
underneath, is passed behind his back. The face looks downward at an 
angle of about forty-five degrees. This enables the blood to flow out 
of the mouth and nares by gravity and keeps it from entering the lar- 
ynx. The operator sits on a low chair, and passes the index-finger of 
the left hand uj) behind the velum as a guide to the forceps, while the 
patient's mouth is held widely open with the gag. The forceps follows 

the finger and, keeping in the me- 
dian line, is opened as widely as 
possible, so as to seize the bulk of 
the adenoid mass at the first intro- 
duction. It is then withdrawn, 
cleaned of adherent flesh, and re- 
inserted. This time it is used to 
cleanse the fossae of Eosenmiiller 
and carefully pluck away all tissue 
near the tubal prominences. The 
small-bladed forcex:>s is often better 
in this region than the large one. 
The forceps follows behind the finger-nail and, guided b}^ the tip of the 
finger, seizes the separate pieces of adenoid tissue. This yields readily 
to the pull of the instrument, while the submucous tissue offers a stronger 
resistance, so that the operator is warned when he has jDassed beyond the 
boundaries of the growth. With care he can avoid seizing the Eustachian 
tubes, which must frequently be palpated to keep their location in mind. 



Fig. 167. 




Allingham's mouth-gag (one-half natural size). 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 443 

To the inexperienced they are apt to feel like tissue requiring removal. 
Having thus taken away all of the growths that can be reached from the 
postnasal space, the nasal bone-forceps is passed along the lower meatas 
on each side of the septum, carefully following the nasal floor until the 
operator feels the beak, which he meets with the index-finger of the left 
hand in the postnasal si)ace. Diaphragms of mucous membrane or ade- 
noid lumps can thus be felt between forceps and finger-tij), which j)resses 
them between the blades of the forceps so that they can be cut away. 
Sometimes the polypoid masses fairly fringe the posterior nares. Open- 
ing the forceps wedges the choan^e open and, if they be too narrow, 
widens them by infraction of the turbinated bones. Any pieces still 
hanging to the pharyngeal A^ault or growing from the posterior wall of 
the nasopharynx can also be brought away with the nasal bone-forceps. 
This comiiletes the operation. The bleeding is free, but soon ceases, 
as the masses are torn, not shaved off, and severe injur}^ to the lateral 
pharj^ngeal wall can hardly happen. Eelapses do not occur ; at least the 
writer has not known of them after hundreds of operations. The pro- 
cedure is, therefore, all that can be desired as regards thoroughness and 
permanency of results, but it is not an operation to be performed by 
one wlio has not made himself thoroughly familiar with palpation of the 
nasoi^harynx. Parents should be told that for a few days or a week after 
the operation children usually do not use their noses for breathing, as 
clots of blood and mucus block the nasal fossse. After this they will 
breathe freely, unless deflections of the septum, or intumescent rhinitis, 
or other obstructions of the nares cause difficulty in nasal respiration. 
In some rare instances children will continue mouth-breathers from mere 
habit. Should a severe hemorrhage occur, the vault of the pharynx 
may be packed in the usual way or, preferably, with a long strip of 
gauze, which is passed through the nares. This strip is saturated with a 
thick solution of tannic and gallic acids, to which inay be added the solu- 
tion of adrenals, as recommended for checking hemorrhage from the 
nares. A recent and very effective preparation is adrenalin chloride, 
which acts vigorously in minute quantities. The strip should be pushed 
back through the nares and then packed behind the palate with the 
finger, which is inserted through the mouth. The nares should also be 
packed, and the gauze brought forward to the nostril to prevent the 
tampon from falling into the throat. This packing should be removed 
within from twelve to twenty -four hours, to avoid the danger of exciting 
inflammation of the middle ear. 

Emil Maj^er does not advocate the radical adenoid operation on very 
young infants, as there is not room for instrumentation. He removes 
as much as he can with the curette, and informs the parents that there 
will probably be a return. Later he performs the radical operation sub- 
stantiallj' as described here. For anaesthesia Mayer employs nitrous 
oxide gas, immediately followed by ether. Chloroform he regards as 



444 DISEASES OF THE NOSE AND NASOPHARYNX. 

dangerous. The objection to the combination mentioned is greater 
bleeding at the time of operation • its advantage is the small amount 
of ether needed. 

After the operation the patient should be kept in bed for a few hours 
and in the house for from two days to a week, according to the weather. 
During this time insufflations of a powder of two per cent, cocaine, fifty 
per cent, iodol, and sufficient sugar of milk to make one hundred parts 
may be made through the nostrils two or three times during the day. 
A simple detergent spray is not objectionable, but washes should be 
avoided for fear of injury to the middle ear; even sprays will some- 
times find their way up the Eustachian tube, and therefore, unless by the 
odor there seems to be a special indication for them, it is preferable to 
use the powder in connection with an antiseptic oily spray contain- 
ing one-third of a grain of thymol, three minims of oil of cloves, and 
one ounce of oleum petrolatum album. The above measures will add 
greatly to the comfort of the patient, but are not absolutely necessary, 
as healing will readily take place without them. 

The children are generally about and playing the day after the opera- 
tion, but perhaps slightly restless and feverish on the first night. If 
deafness exist, the hearing usually speedily improves after removal of 
the adenoids ; but, as mentioned above, this is not always the case, espe- 
cially after the growths have lasted a long time. The operation on 
adults may be performed in the same way or under local ansesthesia, as 
cocaine may be repeatedly and deliberately applied to the nasopharynx, 
and therefore more pronounced local insensibility obtained in grown 
people than in children. Even after prolonged application of cocaine, 
however, the operation is exceedingly painful. When posterior rhi- 
noscopy in adults shows a sessile single mass of tonsillar shape that 
can be included in the ring-knife, this instrument is preferable to the 
Lowenberg forceps when local ansesthesia is used, as reintroduction of 
the forceps to take the growth away piecemeal is very painfal. Eecur- 
rence of the vegetations is not likely to happen in grown people, even if 
the operation be incomplete. 

For sessile growths in the median line the instrument devised by 
Gradle is usefal. The remarkable gain in health and growth in children 
whose adenoid vegetations have been taken away has been commented on. 
There are few operations so beneficial as that for enlarged Luschka's 
tonsil, while the risk incurred is in the vast majority of cases limited to 
the anaesthesia. There is also a slight liability to otitis media due to 
blood or other fluids penetrating the tympanic cavity by way of the 
Eustachian tube. This complication is chiefly observed in children al- 
ready subject to suppurative otitis media. 



CHAPTER XVIL 

TUMORS OF THE NASOPHAEYXX. 

BENIGNANT TUXORS. 

Synonyraes. — Fibroma of the base of the skull, fibroid tumors of the naso- 
pharynx, nasopharyngeal polypi. 

Retronasal Fibrous Tumors. — These growths have a well-defined char- 
acter and originate in the basilar fibrocartilage of the pharyngeal vault. 
They belong histologically to the fibromata. Their character may be 
defined as semi-malignant, and they tend to invade the uares, oropharynx, 
and accessory sinuses by means of prolongations. 

Etiology. — The exciting cause of these tumors is unknown. The male 
sex at or near the period of puberty is especially predisposed, the growths 
occurring chiefly between the tenth and twenty-fifth years. Fibroma 
of the nasopharynx is very rare in women, and in them does not seem 
to belong to any particular period of life. The tumors evince a decided 
disposition to cessation of growth somewhere between the eighteenth and 
twenty-fifth years, and this constitutes a hopeful feature of the disease. 
It is probable that atrophy takes place by fotty degeneration and absorp- 
tion. J. Mikulicz states that the tumors are apt to atrophy about the 
period of puberty. 

Pathology. — The chief place of origin of these fibromata is the fibrocar- 
tilaginous tissue covering the basilar i^rocess of the occipital bone, but they 
]nay also grow from the similar tissue lining the foramen lacerum medium 
and found in the sphenopalatine fossa. In rare cases the growths start 
from the anterior surface of the two up])er cervical vertebrse. The 
tumor is firm and dense, but possesses elasticity, and when cut gives 
the imi)ression of hardness and toughness. The consistency of the 
growth is usually even throughout, though it may contain softer and 
cystic portions. The impression used to prevail that fibroma of the 
nasopharynx contained but few blood-vessels except on its surface, 
this impression being caused by faulty preparation of anatomical speci- 
mens ; but later investigation shows these tumors to be traversed by 
numerous very thin-walled vessels, which often consist of only an endo- 
thelial tube. The vessels become more numerous at the periphery of the 
growth, and their size and number, with the fragility of their walls, 
account for the profuse hemorrhages that occur spontaneously or during 
operations. The unyielding consistency of the growth also keeps the 
severed lumina of the vessels from collapsing and their walls from retract- 
ing within the tissues, so that they remain widely open. 

445 



446 DISEASES OF THE NOSE AND NASOPHARYNX. 

While confined to the nasopharynx the tumor usually presents a 
smooth, intact mucous surface, but when it advances into the oropharynx 
or nose it is liable to superficial erosion or ulceration. Microscopically the 
stroma of the growth consists of dense connective tissue, composed of 
fibres and spindle-shaped connective-tissue cells in varying proportions. 
Numerous round cells are also found, especially about the vessels. The 
connective-tissue fibres unite to form coarse strands, which interlace in 
bundles in various ways, seldom typically, so that there are found irreg- 
ular intertwinings of connective-tissue trabeculae. Histologically these 
growths are to be considered benign, but clinically they often take a 
malignant course. They destroy tissues in their way, not by infiltration, 
as do carcinomata, but by pressure atrophy in the manner of an aneurism. 

Sym])toms. — At its onset the disease causes no appreciable symptoms, 
so that the patient is not seen until nasal stoppage calls his attention to 
the affection. At the same time the remaining symptoms character- 
istic of postnasal occlusions become manifest, — symi)toms which have 
been described with adenoid vegetations, such as snoring, deafness, and 
otitis media. When these disturbances become marked it is usually 
found that the tumor has already attained a large size. Together with 
the symptoms mentioned a serous discharge is often noticed, leading 
the patient to think that he has merely an obstinate cold in the head. 
Instead of the secretions being profuse and serous, they may crust and 
stagnate in the nose, as there is no air-current to remove them. If 
ulceration and sloughing occur, the discharge is apt to be fetid. When 
the tumor grows into the oropharynx, difficulty in swallowing takes 
place. The growth is likely to increase rapidly in this situation, so that 
starvation may ensue. When the laryngopharynx is invaded the voice 
becomes altered, there is danger of suffocation, and tracheotomy maj^ be 
needed. Even when the growth has attained this extreme size it may 
still disappear by absorption. Hemorrhages, often of great severity 
and even gravity, are of frequent occurrence. Nose-bleed is commoner 
than bleeding into the oropharynx. The natuie of the vascular supply 
of the tumor and the denseness of its structure favor obstinate bleeding, 
as mentioned above. A full meal, violent exertion, and bending the body 
far forward are exciting causes of the hemorrhage. Septic sloughs, oc- 
curring spontaneously or after galvano-caustic operations, are liable to 
lead to severe and protracted bleeding when they separate. A singular 
symptom of the ailment is sleepiness, which may overcome the patient 
during his occupation. The gravest symptoms are caused by prolonga- 
tions of the growth. These may enter cavities through their natural 
openings or by pressure on their bony walls, which leads to their local 
absorption and perforation. Growths originating in the sphenopalatine 
or, as it is also called, the sphenomaxillary fossa are denominated retro- 
maxillary tumors. They send prolongations into the nasal cavity from 
their origin, which lies deep beneath the mucous membrane, and continu- 



TUMORS OF THE NASOPHARYNX. 447 

ations into the antrum of Highmore by perforation of its posterior wall, 
while other portions of these tumors cause swellings, which appear above 
the zygomatic i)rocess, in the temporal region, and beneath the malar 
bone. Parts of these neoplasms may enter the orbit by means of the 
sphenomaxillary fissure, or advance into the frontal and sphenoidal 
sinuses or the ethmoidal cells by way of the nares. The deformity 
caused by the invasion of these caA'ities is often extreme. The lower jaw 
api^ears spherically distended, the eye bulges forward, while a tumor 
appears above and below the zygoma. The deformity becomes fright- 
ful in those cases in which the growth extends forward into both nasal 
fossse and orbits. In such cases the nasal bones are wedged far apart, 
broadening the bridge of the nose and forcing the eyes asunder, while 
the orbital prolongations drive them from their sockets. In these in- 
stances a portion of the growth may appear externally and protrude 
from the nostril and orbit. The above tyi)e of deformity is called frog- 
face. An early symptom of retromaxillarj' tumors may be not nasal oc- 
clusion, but distention of the upi^er jaw. Those tumors originating on 
the basilar process of the occipital bone send their j)rolongations into the 
sphenoidal, frontal, and maxillary sinuses and the ethmoidal cells, usu- 
ally by penetration and widening of their natural orifices, but also by 
causing pressure atro^Dhy and absorx:)tion of their bony walls. The pro- 
longations into the ethmoid bone are the most dangerous. In the course 
of time they may enter the ciimial cavity through i:)erforations caused by 
absorption of the thin structure of this bone, and then lead to meningitis 
or, more rarely, to brain-abscess. These outgrowths from the neoi^lasm 
belong t«o its later stages, and are generally characteristic of neglected 
cases. 

Those growths found on the posterior wall of the nasopharynx gen- 
erally have no prolongations. They originate on the j)revertebral tis- 
sues, form rounded, easily enucleated tumors, and are the most benign 
of the fibromata of the rhinopharynx. In rare cases thej^ penetrate the 
lateral region of the neck by means of extensions. Fibroid tumors of 
the nasopharynx are hardly ever seen until they have attained a con- 
siderable size. Inspection of the nares shows in one or both a finger-like 
prolongation of the neoplasm, or merely that the posterior end of the 
nasal fossa is occluded by an obstructing mass. In rare cases the tumor 
can be seen to project from the nostril as an ulcerated growth, its color 
varying from pink to dark red. 

Inspection of the pharynx shows the soft palate pushed downward and 
forward if the tumor be of sufficient size. Posterior rhinoscopy reveals 
a large, smooth mass filling the nasoiDharynx and hiding it and the 
choanae from view. The growth may present a clean ai)pearance or be 
covered with muco-pus, mucus, or bloody crusts, and display superficial 
ulcerations. In other cases the secretions are present in such amount 
that they cover up the growth, which becomes visible only when they are 



448 DISEASES OF THE NOSE AND NASOPHARYNX. 

washed away. In a number of cases a portion of the tumor can be seen 
protruding into the oropharynx, and may be directly inspected. When 
washed free from adherent secretions the color of the tumor in the naso- 
pharynx is dark pink or red, and not translucent, as are mucous polypi, 
as a rule. 

Palpation with the probe in the nose or nasopharynx will offer a firm 
and elastic resistance, while the finger in the nasopharynx will encoun- 
ter the same characteristics. The probe is to be used with caution, as 
severe bleeding occasionally follows its use and may put a stop to further 
investigations. The tumor is but moderately movable or may be found 
firmly fixed by adhesions and prolongations. Prolongations into the 
orbit may announce themselves at first by inducing optic nerve atrophy, 
or by displacing the globe in various directions, causing diplopia. Pro- 

FiG. 168. 



S^-tf 







Fibrosarcoma of the postnasal space of a seventeen-year-old youth. Right tubal orifice displaced 
forward, left compressed. The tumor is for the most part covered with tough yellowish secretion. 
(Mikulicz and Michelson.) 

longations into the cranial cavity may be difficult of diagnosis, and for a 
long time set up obscure symptoms, which become definite when there is 
intracranial pressure. 

Severe neuralgias may be occasioned by pressure of the growth on the 
second and third divisions of the fifth nerve as it i:)asses through the 
foramen ovale or rotundum. The pain may be agonizing and be located 
in the uj^per or lower jaw, or both. If the eye be not dislocated and pain 
be felt in all three branches of the fifth nerve, the Gasserian ganglion is 
involved, and the cranial cavity has therefore been entered by the tumor 5 
but if there be forward displacement of the eye, the neuralgia may be 
due to extracranial pressure on all three divisions of the fifth nerve. The 
motor nerves of the eye- muscles are also liable to paralysis from com- 
pression, but disturbances of the motions of the eye are more often due 



TUMORS OF THE XAbOPHARYNX. 449 

to displacement of the globe mechanically by the advancing tumor. 
Adhesions are apt to result from unsuccessful attempts at removal of the 
growth. The discovery of these and of the separate prolongations of the 
tumor is often not possible, except during operations for its removal. 

Diagnosis. — The differential diagnosis from malignant sarcoma may 
not be x>ossible even with the microscoi)e. Sarcomata are less apt to 
form a well-defined tumor than fibroid tumors of the nasopharynx, and 
tend to invade the neighboring tissues, not by displacement, but by 
directly entering them with their histological elements. Mucous polypi 
may become so large as to fill the entire postnasal space. They are, 
however, seldom red, but usually of a characteristic glassy gray and 
translucent, and are far more freely movable than fibromata. The pro- 
longations of the latter into the nares, however, may appear oedematous 
and translucent, and so be mistaken for mucous polypi. 

One might possibly confound hypertrophy of Luschka's tonsil with 
fibromata, from which it will be differentiated by the age of the patient, 
its slower growth, and by its having a lighter color, more irregular sur- 
face, and less density. Adenoid vegetations in the vault of the pharynx 
do not bleed so profusely when handled as the fibromata, and are soft, 
irregular, and occur at an earlier age. 

Frognosis. — The growths tend steadily to increase in size, and, unless 
recognized and removed, will in most cases i^rove fatal in the course of 
four or five years. Even when removed there yet remains a strong ten- 
dency to recurrence ; but, fortunately, if they can be kept in check until 
the patient has attained the age of from twenty to twentj^-five years, there 
is a disposition to spontaneous arrest of development. 

Treatment. — The use of caustics and the attempt to reduce the growth 
by the application of other chemicals have been abandoned in the treatment 
of fibrous tumors of the nasoj^harjaix. The galvano-cautery is employed 
for destruction of nasopharyngeal fibromata, and has been used in the 
form of a large porcelain btumer or the cauterj^ knife. With the former 
several sittings are needed, the large sloughs formed are liable to cause 
sepsis and lead to dangerous hemorrhages, and the great heat developed is 
apt to burn neighboring structures and cause adhesions which add enor- 
mously to the difficulties of radical removal. Excisions of pieces with 
the cautery knife or punctures with pointed electrodes have been fol- 
lowed by shrinkage of the tumor. The best method outside of opera- 
tive removal is that by electrolysis. By means of a carbon rheostat and 
an electric light in circuit, in connection with a series plug, the direct, 
not alternating, street current, usuallj^ having one hundred and ten volts, 
can be used, and will furnish a current equalling that obtained from fifty- 
five very active cells, a larger battery than is ordinarily assembled. To 
furnish the required current from a battery at least thirty cells, and prob- 
ably forty or more, will be needed, unless the battery be very active. Cur- 
rents up to three hundred and forty milliamperes have been used, but 

29 



450 DISEASES OF THE NOSE AND NASOPHAKYNX. 

anything above seventy or eighty will make a general ansesthetic neces- 
sary on account of the great pain produced. When currents of this 
high amperage are used the proximity of the brain is to be considered, 
as enough of the electricity may traverse it to cause syncope. With the 
very strong currents mentioned the growth can be destroyed in a few sit- 
tings, and the danger of sepsis from sloughing is less than when weaker 
ones are employed, as the tumor is cast off more rapidly. This danger 
is one of the drawbacks of electrolysis when employed for the removal 
of nasopharyngeal fibromata. Gangrenous and phlegmonous processes 
may accompany the casting off of the deep sloughs, and a fatal menin- 
gitis is recorded. A good strength for most cases is from forty to sixty 
milliamperes. Currents of even this moderate strength are very painful, 
but good local anaesthesia and very gradual introduction of the current 
will do much to moderate the pain. One or more needles may be used 
for the negative pole, while the positive electrode may be a large sponge 
applied to the back, the so-called monopolar method, or preferably a 
needle inserted into another part of the growth, the bipolar method. 
The needles may be introduced through the nose or nasopharynx, and all 
but the exposed ends must be well insulated. The current may be con- 
tinued for from ten to fifteen minutes. The operation must not be re- 
peated under from ten days to two weeks, or even longer, as the sloughs 
must have time to separate before new ones are created. This will di- 
minish the danger of septic processes, which can also be minimized by 
cleansing irrigations of the nares and nasopharynx with mild antiseptic 
solutions and the free insufflation of iodol. A long time is usually re- 
quired for treatment, even one hundred sittings being needed in some 
cases. When very strong currents are used ten operations may suffice. 

When the patient will consent to operative removal of the growth 
this method is preferable, unless extensive adhesions be present and 
occasion a difficult and bloody operation, or the great size of the tumor 
makes it desirable to reduce it before attempting to take it away with 
instruments. The operations for ablation of the tumor are of two types : 
the first includes those methods which remove the growth by the natural 
passages, the second those that require preliminary resection of parts in 
the way of the neoplasm by surgical methods. These latter operations 
belong to general surgery. The firm, broad attachment of the tumor to 
the base of the skull makes its removal by evulsion with strong postnasal 
forceps not impossible, but dangerous, as great force is required ; and if 
the neoplasm have entered the bony structures towards the cranial cavity, 
penetration of the dura mater and meningitis may occur. The bleeding 
after evulsion is moderate. 

The tumor can be remoA^ed piecemeal by Lowenberg's or other cutting 
forceps for postnasal operations, or it may be cut away with a curved 
blunt-pointed bistoury, a curved scissors, or a gouge. Any of these 
methods is ai3plicable in some instances, but they are apt to be attended 



TUMORS OF THE NASOPHARYNX. 451 

by profuse hemorrhage, and if much force be used the resulting inflam- 
mation may prove fatal by extension to the brain. The growth may be 
torn away by the fingers when it is of the enucleable variety. This 
method is especially applicable to very large tumors. Two fingers are 
introduced into the nasopharynx and hooked over the tumor, while the 
index-finger of the other hand is passed through the nostril, which is 
generally widened by the dilating j^ower of a nasal i)rolongation. Great 
force is required, and perforation of the cranial cavity may occur. 

Ligature of the growth with the intention of having it subsequently 
come away by gangrene due to interrupted circulation has been aban- 
doned as dangerous, on account of the great risk of resulting septic pro- 
cesses. 

When the case is suitable for their employment snare operations 
are to be preferred to all others. When the tumor is pedunculated it 
may sometimes be secured in the loop of an ecraseur, but more easily in 
a loop of steel wire with the ordinary snare ; usually the tissue is so 
firm that it cannot be cut with 

the cold wire snare. The No. ^^^'- ^^^• 

5 piano-wire used for mucous 
polypi is liable to break, and 
wire of larger size cuts the tis- 
sue much less easily, so that 

it cannot be drawn through Ingals's postnasal snare applicator (one-third natu- 

the liedicle excerpt with a ^""^ ^''■^^- For tumors in nasopharynx. The wire loop 
me peaiCie except Wim a .^ j^^^^ ^^ notches at D by the slides B, C, which are 

stronger and much more pOW- held firmly by the cam ,-l. As the loop is carried behind 

erful instrument. The galvano- *^^ p^^^*^ *^^ ^^^^'^^' ^'^ °p^"^^ f *^^* *^^ ^^'^ ^^- 

° _ closes the tumor ; it is then tightened, the cam is 

cautery snare (Fig. 125) is the loosened, the slides^, care drawn slightly backAvard, 

best instrument for the removal ^"^ *^^ ^^ '"^^ ^^ released and left in position while the 

applicator is withdrawn, 

of these tumors whenever they 

are sufficiently pedunculated to allow of its employment. In performing 
the operation two soft catheters should be passed through the naris, 
endeavoring to carry one on each side of the growth and to bring them 
out of the mouth. Into the ends that are brought out of the mouth 
the ends of a piece of No. 20 platinum wire about three feet in length 
are introduced and pushed on until they come out of the nostril. A 
thread is attached to the wire loop to enable the operator to draw it 
backward in case of failure in the first attempt to place it about the 
tumor. The catheters with the wires i)rotruding from the nostril are now 
drawn upon, and the loop, passing back into the mouth, is carried with 
the finger, or with the aid of a postnasal snare applicator (Fig. 169), up 
about the tumor, where it is drawn firmly into place. The catheters 
are then withdrawn and the wires intrusted to an assistant, who holds 
them carefully to iDrevent their becoming crossed in the naris. The ends 
of the wire are then slipped through the tubes of the galvano- cautery 
ecraseur and fastened to the ratchet on the handle. It is desirable to have 




452 DISEASES OF THE NOSE AND NASOPHARYNX. 

the distal ends of this electrode separated about a quarter of an inch, or 
even more, so that it may be the more readily passed upon either side of 
the tumor. As the instrument is pushed into the nose the ratchet is 
turned to tighten the loop, which is drawn tight upon the pedicle of the 
tumor before the electric current is turned on. 

As it is very difficult to adjust the platinum loop i)roperly with the 
patient under ether or chloroform, it is better to rely on the anaesthetic 
effect of cocaine 5 but its benumbing quality in this locality is not suffi- 
cient to prevent considerable pain during the burning off of the growth ; 
therefore, when everything is in readiness, the iDatient should be told to 
bear the burning as long as possible, and that the current will be stopped 
as soon as he requests it. The current is then turned on and the ratchet 
tightened at the same time. The patient will endure the pain two or 
three seconds, then the circuit is broken and he is allowed to wait two or 
three minutes ; as soon as he is again ready the circuit is again closed, 
and thus the process is continued until the pedicle is burned through. 
The tumor is then seized with a pair of postnasal forceps and withdrawn 
through the mouth. There is little or no hemorrhage from this operation. 

The usual lightness of the tubes attached to the gal vano- cautery 
handle for conveying the snare makes their extremities liable to spread, 
so that they at times permit a piece of the growth to enter between them. 
This piece will not be burned through, and therefore has to be torn away, 
with perhaps considerable bleeding as a result. It is, therefore, of ad- 
vantage to unite the extremities of the tubes with a small piece of ivory 
drilled to receive them. 

The current used should be just strong enough to make the wire cut 
readily. A white heat is apt to cause bleeding or to melt the wire, and 
this accident usually leads to severe hemorrhage. The melting may occur 
if a part of the wire be not firmly drawn against the growth, so that it gets 
hot in the air ; therefore the loop should always be drawn tight before 
the current is turned on. When nasal prolongations are extensively ad- 
herent, or the sinuses are invaded by the growth, it may be impossible to 
apply the snare by way of the nares, and be necessary to slip it over the 
growth from the nasopharynx with the fingers. This is a very difficult 
manipulation, as the wire loop is apt to be bent out of shape. The snare 
tubes must have the proper nasopharyngeal curve. It is often impos- 
sible to ai3ply the snare over the broadly attached and perhaps adherent 
tumor, and in this case the methods of operation described above must be 
resorted to. 

Whenever, as the result of an operation, hemorrhage ensues, it may 
be necessary to plug the posterior nares. For this purpose the most satis- 
factory proceeding is that of passing through the naris a long strip of 
gauze, rendered styptic by saturation with tannic and gallic acids, as 
recommended in the treatment of epistaxis. The gauze is pushed back 
with the nasal probe or nasal scissors through the naris to the naso- 



TUMORS OF THE NASOPHARYNX. 453 

pharynx, and is there packed into the vault, with the finger carried 
up behind the palate. Finally, the naris itself is completely filled to 
prevent the plug from falling into the throat if it should become 
loosened. The tampon should be removed within from twelve to twenty- 
four hours by traction ui)on the end protruding from the nostril, by 
which the strip is gradually unfolded. In case clotting of blood has 
rendered the tampon hard and bound its folds together, it should be 
softened by gently injecting into the nostril a warm solution of sodium 
bicarbonate. Should recurrence of the tumor take place, it should be 
treated while yet small by the gal vano- cautery or electrolysis, or by injec- 
tions into the growth, by means of a long hyi^odermic needle, of a solution 
of from three to five per cent, of carbolic acid with from fifteen to thirty- 
five per cent, of lactic acid in water, the weaker solution being used at 
first and the strength gradual!}" increased with subsec[uent injections. 
To prevent pain the injection should be preceded by a few drops of a 
four i^er cent, solution of cocaine. When retromaxillary fibroid tumors 
originating in the sphenomaxillary fossa become very large they must be 
removed from without by temporary resection of the zygomatic process, 
and at times of the coronoid ijrocess of the lower jaw 5 they belong, 
therefore, to general surgery, and cannot successfully be attacked from 
the nasal fossae or nasopharynx. When the tumors are not more than 
one and a half inches in diameter they can be reduced by the lactic acid 
injections. Preliminary operations opening the way to the tumor are 
becoming less necessary as the methods for operating through the natural 
passages improve ; but when the period of puberty is past, and the tumor 
recurs obstinately after operations from the nares or nasopharynx, pre- 
liminary oi^eratious may be needed in order radically to extirpate the 
growth. Examples of these are temporary resection of the uj)per jaw, 
or temporary separation of both upper jaws, or resection of the entire 
external nose. When the tumor reappears often after operation a strong 
suspicion of malignancy is justified. When it is suspected that the 
tumor has penetrated the cranial cavity, general surgical measures open- 
ing widely the way to the field of operation are to be preferred to opera- 
tions by the natural passages, as sepsis and injury to the brain are less 
likely to occur. As a general rule, the methods of general surgery are 
to be tried only after operations through the nose or nasopharynx fail 
to relieve the patient. 

Eetronasal Fibromucous Tumors. — Eetronasal fibromucous polypi are 
smooth, more or less ovoid tumors, varying from three-quarters of an 
inch to four inches in diameter. They cause obstruction of the posterior 
nares, especially in expiration, with consequent inability to blow the 
nose. They are less frequent than fibrous tumors. 

Fathology. — These growths usually spring from the posterior border 
of the septum, or less often from the rim of the choanse or under surface 
of the body of the sphenoid bone. Their origin, therefore, is close to the 



454 DISEASES OF THE ^^OSE AND NASOPHARYNX. 

posterior iiares, and they resemble the nasal mucous polypi. Their histo- 
logical structure is identical with that of the latter growths, the amount 
of fibrous tissue in their composition varying as it does in them. They 
generally, however, contain an excess of fibrous tissue, and are more 
dense than most mucous polypi. Those tumors growing from the pos- 
terior third of the nares are apt to be like the ordinary mucous polypus, 
while those originating back of this situation from the tissues near the 
posterior nares are generally more fibrous in character. The size of the 
tumors may be great enough to completely fill the nasopharynx. 

Symptoms. — The symptoms are merely those of nasal obstruction which 
slowly increases, and, in fact, are identical with those created by nasal 
mucous polypi. Thus there are observed the dead voice, the mouth- 
breathing, and the other conditions described under these growths. 

Diagnosis. — The tumors are readily diagnosed from retronasal fibrous 
tumors by their softness, great elasticity and mobility, lack of ten- 
dency to bleed when touched or to cause 
Ftg. 170. frequent nose-bleed, the fact that they do 

not displace bony structures, and that they 
remain confined to the nasopharynx. Nasal 
mucous polypi can be diagnosed only by 
their seat of origin, as their structure is 
identical with that of the growths in ques- 
tion. Those containing more fibrous tissue 
and blood-vessels than usual are of darker 
^ \ / color and firmer than the average mucous 

"W polypus. The differential diagnosis be- 

Retronasaifibromucous tumor. ^^^^^ ^^^^i niucous polypi and retronasal 

fibromucous tumors is not of practical con- 
sequence. The latter are distinguished from malignant growths by the 
history, absence of pain and hemorrhage, smooth surface, and less degree 
of density. 

Treatment. — These growths, if not too firm, can be removed with the 
steel- wire snare. When they are large and tough the hot snare may 
answer the purpose better. The bleeding during the operation and after- 
wards may be considerable, but can largely be controlled by the free 
use of adrenals. In most cases the wire loop can be passed over the 
tumor after the snare has been pushed through the naris, while the finger 
in the nasopharynx assists in adjusting the wire over the growth. If a 
loop cannot be slipped over the neoplasm, this can be torn away with 
postnasal cutting forceps of the Lowenberg type, as there need be no 
fear of so much hemorrhage as occurs in operating on nasopharyngeal 
fibrous tumors. 

Retronasal Cartilaginous Tumors and other Bare Benign Growths. — The 
extreme rarity of these neoplasms makes it sufficient to merely mention 
them. Besides several cases of enchondroma, one of lipoma has been 




TUMORS OF THE NASOPHARYNX. 



455 



noted, also a few of papilloma. Cysts of the nasopharynx are found in 
the region of the bursa pharyngea. are of the retention variety, and have 
been considered under chronic rhinopharyngitis. 



MALIGNANT TUMORS OF THE NASOPHARYNX. 

Primary malignant growths of the nasopharynx are very rare. Sec- 
ondary carcinoma is less infrequent, as epithelioma of the tonsil and soft 
palate often invades the ijostnasal space. 

Pathology. — Both sarcoma and carcinoma are found in the naso- 
pharynx. Sarcoma is of the spindle- celled or of the more malignant 

Fig. 171. 




4 J 

Round-celled sarcoma of nasal cavity and nasopharynx. (Stoerk.) a, vault of pharynx ; 6, sphe- 
noidal sinus ; c, body of sphenoid bone ; d, spinal column ; e, hard palate pierced by tumor ; /, uvula 
displaced forward. 

round-celled type. A third variety of malignant growth verj' seldom 
found and mentioned among nasal malignant tumors is endothelioma. 
This has also at times, though very rarely, its seat in the nasopharynx. 
The commonest place of origin for all the types of malignant growths is 
tlie vault of the pharynx in the region of the pharyngeal tonsil. Oc- 
casionally they have grown from the posterior and lateral walls of the 
nasopharynx. 

Carcinomata show their usual early tendency to ulceration as they 
advance and destroy the tissues in their path, so that tumor formation 
is less cliaracteristic than disintegration. Sarcomata are less i^rone to 
ulcerate, but form large growths, which not only cause absorption of bony 



456 DISEASES OF THE NOSE AND NASOPHARYNX. 

substance or other tissues, as do fibromata, but substitute their neoplastic 
histological elements for the normal ones of the structures encountered. 
Thus the danger of invasion of the cranial cavity by malignant tumors 
is far greater than in simple fibromata. 

Symptoms. — Sarcomata, present symptoms like those of retronasal 
fibrous tumors, due to filling up of the postnasal space with the growth. 
The ulceration of carcinoma usually prevents its forming tumors of great 
size, but its destructive action is more marked. Endothelioma forms a 
large grayish-pink, friable tumor which is noticeable for its softness and 
rapid, exuberant growth. As is the case in fibrous tumors of the naso- 
pharynx, the malignant growths are insidious in their course, and be- 
come noticeable only when they occlude the nasal passages, or when, 
by penetration of the base of the skull, they develop nervous symp- 
toms. These consist of neuralgias and ansesthesias of the second and 
third divisions of the fifth cranial nerve as they pass through the 
foramen ovale and rotundum in the sphenoid bone. Paralyses of the 
optic nerve, the fourth, sixth, and third cranial nerves, with loss of 
motion of the ocular muscles supplied by them, also occur. Later in the 
affection the facial nerve may be involved. A paralysis of all the 
muscles supplied by the branches of the third cranial nerve, without 
accomiDanying exophthalmos, together with evidence of a tumor in the 
nasopharynx, betokens the malignancy of the latter. Carcinomata and 
often sarcomata disintegrate by slougliing and ulceration, often creating 
an intolerable stench. Severe hemorrhages accompany this process, and 
profuse bleeding marks the course of all these tumors. In youthful in- 
dividuals some sarcomata consist mainly of blood-vessels. 

Diagnosis. — The diagnosis of retromaxillary and nasopharyngeal 
fibroma from sarcoma may be impossible even with the microscope. 
Fibromata having an obstinate tendency to recurrence and showing a 
semi-malignant disposition to invade other cavities than the nasopharynx 
are often mistaken for sarcoma. The latter not only displaces bone, 
but enters into the structure of surrounding parts, so that it does not form 
so well-defined a tumor as fibroma. This characteristic may, however, 
be imi)0ssible to determine during life. 

The great destructiveness, ulceration, and foul stench of carcinoma, 
together with the small tendency to tumor formation, severe neuralgic 
pains, and cachexia, should sufiBLce to distinguish it from fibroma. The 
other innocent growths of the nasopharynx are mostly polypoid and 
pedunculated, and can hardly cause any difficulty in the diagnosis. 

Prognosis. — Death occurs as the result of exhaustion, profuse hem- 
orrhage, aspiration-pneumonia, or operations undertaken for the relief of 
the condition. 

Treatment. — As soon as it is recognized that the nasopharyngeal tumor 
is malignant, treatment, if the growth be seen early, should consist in 
extirpation by the means suggested in the article on retronasal fibrous 



TUMORS OF THE XASOPHARYXX. 457 

tumors, and cauterization of its base with the galvano-cautery. Unfor- 
tunately, the tumors are almost invariably seen too late for more than 
palliative operations with the snare or other instruments. The more 
radical procedures by preliminary surgical operations giving access to the 
parts are to be undertaken only when the growth has made but little 
advance, otherwise they are useless. 

In sarcoma the injection of the toxins of erysipelas and the bacillus 
prodigiosus should be attempted in the hope of causing absorption of 
the growth. Lactic acid in the strength mentioned under retronasal 
fibrous tumors and alcohol injections may also be tried with good result. 



CHAPTEE XYIII. 

SYPHILIS AND TUBERCULOSIS OF THE NASOPHARYKX. 
SYPHILIS OF THE NASOPHARYNX. 

Infection from Eustachian catheters which have been contaminated 
by syphilitic poison has caused quite a large number of cases of hard 
chancre of the nasopharynx. This has made its appearance on the 
dorsum of the soft palate, the salpingopalatal fold, and in the neigh- 
borhood of the Eustachian opening ; in fact, in places which the catheter 
Is likely to scratch during its introduction. The catheter may, however, 
not produce an initial lesion in the nasopharynx at all, but this may 
appear on the faucial tonsil. Primary syphilis of the nasoi)harynx is 
characterized by extensive induration, a tendency to destructive ulcera- 
tion and inflammation of the surrounding tissues, while a large indo- 
lent, bubonic mass of lymphatic glands occupies the submaxillary region. 
The ulceration may cause perforation of the soft palate or periostitic 
processes. 

Secondary syphilis may invade the nasopharynx, and is apt to lead to 
pronounced deafness of rather acute onset and frequently to otalgia. 
The deafness is due in some cases to syphilitic swelling of the pharyngeal 
tonsil. Superficial secondary ulceration (in rare cases deeper and more 
serious), papules, and condylomata may be seen on the dorsum of the 
velum, about the tubal orifices, and in the recessus pharyngeus. The 
pharyngeal tonsil may be swollen and present superficial ulcerations. 

Tertiary syphilis of the nasopharynx seldom occurs before the second 
or third year after infection, and may be seen from twenty to fifty years 
after. Hereditary syphilis may not make its appearance until puberty 
or later, and may cause great damage to function by resulting cicatrices 
and perforations of the palate. Tertiary syphilis of the nasopharynx 
is usually associated with that of the nose or oropharynx, but may 
exist as an independent affection. It appears, as elsewhere, in the form 
of a gumma, arising in the submucous tissues as a formidable typical 
deep, clean-cut tertiary ulcer and as the brawny syphilitic infiltration 
of the mucosa of more superficial nature. This latter form is apt to 
lead to serpiginous, shallow ulceration. The deep ulceration is especially 
likely to attack the dorsum of the soft palate and destroy it extensively, 
so that when a small perforation appears on the oral surface the way 
is prepared for its rapid and extensive advance by the ulcer on the 
dorsum. In this manner in a short time the soft palate and part of the 
hard palate may be destroyed. Other tertiary ulcers involve the vault of 
the pharynx, the posterior wall of the rhinopharynx, the Eustachian 
458 



SYPHILIS AND TUBERCULOSIS OF THE XASOPHARYXX. 459 

tubes, and the free border of the septum, resulting in necrosis of a i^art 
of the posterior portion of the vomer. The circumference of the choau?e, 
the posterior ends of the turbiuals, and other structures may be attacked 
by ulceration. Tertiary syphilis, especially of the hereditary type, is 
responsible for a number of the cases of enlarged pharj'ngeal tonsil which 
come to the surgeon for operation. Besides necrosis of the x)Osterior part 
of the vomer, the basilar process of the occipital bone, the posterior ends 
of the turbinated bones, and the anterior parts of the upi)er cervical 
vertebrae are liable to caries and necrosis. Tertiary nasal syphilis usu- 
ally accompanies that of the nasox)harynx, and the patient's complaints 
attract attention to the nose rather than to the i^arts back of it, as the 
stoppage of the nares and the foul nasal discharge are the most prominent 
symptoms. 

The usual local symptoms caused by tertiary nasopharyngeal syphilis 
are obscure unless x)Osterior rhinoscopy be employed. AVhen oral, nasal, 
or pharyngeal syphilis, or the presence of the disease elsewhere, directs 
attention to its nature, syphilis of the nasopharynx maj be suspected, 
otherwise the symptoms are apt to be attributed to catarrh or catarrhal 
deafness, while irremediable destruction is occurring in important parts. 
The chief symptoms are dysphagia, which may be severe, pain in the 
occipital and temporal regions and in the ears, tinnitus aurium, deafness, 
which may become absolute, dizziness, occluded nasal resi^iration, and 
collection of secretions in the nasopharynx. 

Secondary syphilis usually leaves no trace of its presence in the naso- 
pharynx after it has healed, though in rare cases it proves destructive. 
The consequences of primary syphilis in the nasopharynx have been con- 
sidered. Tertiary syphilis is recognized early, and in its milder forms 
may do but little permanent damage, while in its grave variety it may 
cause serious lesions, great deformity, and even threaten life. Ulcera- 
tions of the borders of the choanae are ajA to lead to cicatricial stenosis 
of these passages, or in children to their complete atresia. In like man- 
ner cicatrices may cause partial or complete closure of the tubal orifices 
and resulting deafness. Loss of the soft and part of the hard palate 
may result from ulcerations working their way through these parts from 
the nasoi:)harynx. Caries and necrosis of the anterior surfaces of the 
uiDper cervical vertebrie may lead to retropharyngeal abscess and even 
oj^en the spinal canal, with resulting paralysis due to involvement of the 
spinal cord. 

Diagnosis. — The secondary symptoms localized in the nasoi)harynx are 
associated with signs of the disease elsewhere, and therefore are not liable 
to be assigned to any other cause. The deafness may, however, be mis- 
leading when the possibility of syphilis is not kept in mind and its gen- 
eral symptoms are too slight to attract notice. The most serious mistakes 
occur when tertiarj- syphilis of the nasopharynx is overlooked because 
posterior rhinoscoi3y has not been performed. It seems incredible that it 



460 DISEASES OF THE NOSE AND NASOPHARYNX. 

should be omitted as often as it is in throat examinations. Tertiary syphilis 
of the nasopharynx may thus be supposed to be merely a chronic postnasal 
catarrh, with possibly accompanying deafness. Inspection of the parts 
will, of course, at once differentiate the two affections. Carcinoma does 
not have such clean-cut ulcerations as syphilis ; the borders of carci- 
nomatous ulcers merge insensibly into the surrounding hard infiltration 
of carcinoma, which is of a paler color and not so smooth as the gummy 
infiltration surrounding the tertiary syphilitic ulcer. In carcinoma the 
ulceration progresses much more slowly than does that of tertiary syphilis, 
w^hile the characteristic pain and cachexia of carcinoma accompany it. 
In carcinoma there is enlargement of the lymphatic glands in the neck 
and under the jaw, while lymphatic- gland involvement is rare in syphilis 
in the tertiary period. Chancre of the nasopharynx is accompanied by a 
hard, dense, bubonic enlargement of the submaxillary lymphatic glands. 
There is a marked inflammatory halo about the chancre, and its borders 
are harder and more indurated than those of the gummatous ulcer. 

Prognosis. — This is favorable when the disease is recognized early, but 
if extensive ulceration exist, even if this can be caused to heal, deform- 
ing scars are liable to result which may occlude the posterior nares, 
close the Eastachian tubes, or even cause the soft palate to unite with the 
posterior wall of the pharynx and partly or completely shut the naso- 
pharynx off from the oropharynx. Necrosis of the base of the skull or 
of the vertebrse may lead to fatal complications of the spinal cord or 
brain. Extensive ulceration destroying the soft and hard palates may 
leave the oral and nasopharyngeal cavities united. Chancre of the naso- 
pharynx usually lasts from six weeks to two months. 

Treatment. — Considering its seat and the importance of the structures 
liable to injury, it is better to make an exception to the usual rule of 
waiting for secondary symptoms in the case of chancre of the naso- 
pharynx and to begin constitutional treatment at once with the usual 
methods employed for secondary syi)hilis. Locally, insufflations of 
calomel, one-eighth of a grain three times a day, rubbed up with bismuth 
subnitrate or iodol, are useful, combined with irrigations of potassium 
permanganate, one-eighth of a grain to the ounce, applied with Freer' s 
hard-rubber irrigating tube passed through the nares. Secondary syphilis 
of the nasopharynx requires no local treatment, but energetic constitu- 
tional measures. If the patient want something done locally, iodol 
insufflations can be used. Should the physician wish to avoid the danger 
of contagion, he can teach the patient to use the insufflations and irri 
gations himself. In tertiary syphilis of the nasopharynx, jDotassium or 
sodium iodide should be pushed to the physiological limit of tolerance. 
The ulcerations often refuse to heal until sequestra of dead bone from the 
vomer or base of the occipital bone or carious portions of other bone are 
removed. It may be necessary to curette the ulcerations with a sharp 
spoon. As a rule, how^ever, constitutional treatment will speedily put a 



SYPHILIS AND TUBERCULOSIS OF THE XASOPHAEYXX. 461 

stop to the disease. Locally, cleansing irrigations may be needed, and 
the ulcers will sometimes heal very promptly if touched daily for ten 
or twelve days with a strong tincture of iodine until the surface has a 
dry, glazed, brown aspect. If this treatment prove too irritating, swab- 
bing with a sulphate of coi:)per solution, from ten to twenty- grains to 
the ounce, may be substituted for a few days. 

TUBERCULOSIS OF THE NASOPHARYNX. 

The nasopharynx, especially when deprived of its normal epithelium 
by frequent catarrhal states, is doubtless the place of entrance for the 
tubercle bacillus into the lymphatic system in some cases which develop 
tuberculosis of the lymphatic glands, and later pulmonary tuberculosis. 
While the lymphatic tissue of the nasoj^harynx gives ready passage to 
the tubercle bacillus, especially when it is diseased, as in hyperj)lasia due 
to catarrhal states, nevertheless, tuberculosis very seldom manifests itself 
in the nasopharynx, as the tissues of this region evidently form a i^oor 
soil for its localization. 

Etiology. — Tuberculosis of the nasoj^harynx is seldom primary, except 
in the case of tubercular tumors. The ulcerations are almost always 
secondary to advanced pulmonary consumption, and are caused by auto- 
infection of the nasopharynx with sputum. E. Frankel, from examina- 
tions of phthisical cadavers, has proved that in the late stages of phthisis 
the tubercular ulcer of the nasopharynx is not especially rare, but is not 
discovered in moribund patients. 

Fatliology. — The disease manifests itself in the form of ulcerations, 
tubercular tumors, and tuberculosis of the adenoid vegetations. The latter 
condition has been considered under enlargement of the pharyngeal tonsil. 
Tubercular ulcers of the nasoj)harynx occur most frequently on the 
pharyngeal vault ; next in frequency they attack the tubal prominences. 
Thej^ may also appear on the dorsum of the soft palate, the sides of the 
nasoj)harynx, or in the fossa of Eosenmiiller. Ulcerations of the ends 
of the Eustachian tubes may result in their destruction. The character 
of the ulcers is that of tubercular ulcerations of the mucous membrane. 
The bottom is pale, often covered with purulent secretions, and apt to 
display sprouting, exuberant granulations. The ulcer has an ill-defined, 
irregular border, and is surrounded by miliary tubercles. The tissue in 
which the ulcer is seated is pale, and does not appear actively inflam- 
matory. The losses of tissue are generally superficial, but in some cases 
the ulcers are deep and destructive, though not to the same extent as 
those of syphilis. 

Tubercular tumors of the nasopharynx may occupy various situations 
in this cavity, such as the posterior part of the septum, the choanse, and 
the back of the velum. Thej^ vary in size from a hazel-nut or smaller to 
tumors that fill the nasox)harynx, and may be taken for malignant growths. 
They have a smooth, not ulcerated, surface, may be lobed, and are of a 



462 DISEASES OF THE NOSE AND NASOPHARYNX. 

pale pink color. Histologically, they consist of adenoid tissue contain- 
ing many typical tubercles with giant cells and bacilli. The latter are, 
however, very few in number. The miliary tubercles may coalesce and 
undergo cheesy degeneration. 

Symptoms. — Tubercular tumors cause the symptoms of other growths 
in the nasopharynx. They are anaemic, and have no especial tendency 
to bleed. Tubercular ulcers, especially with advanced pulmonary con- 
sumption, are generally latent and not discovered. In other cases they 
cause pain and dysphagia. 

Diagnosis. — In the case of tubercular tumors microscopic examination 
will be needed to establish the diagnosis. The ulcers may be confounded 
with those of syphilis, but as the symptoms of pulmonary tuberculosis — 
fever and emaciation, with rapid pulse — generally coexist, a mistake is 
unlikely. In doubtful cases antisyphilitic treatment must be used to 
establish the diagnosis. 

Prognosis. — If the tubercular tumor be removed completely the prog- 
nosis is likely to be favorable, as the disease is more apt to be a primary 
process than is the tubercular ulcer. The prognosis of the latter is un- 
favorable because of the accompanying pulmonary consumption. 

Treatment. — This consists in removal of the tubercular tumors with 
the steel-wire snare and cauterization or curettement of the stump. As 
these tumors are soft and friable, they can readily be removed in this 
way. Tubercular ulcers should be curetted and cauterized with from fifty 
to one hundred per cent, lactic acid or the galvano-cautery. If the dis- 
ease form a complication of advanced consumption, palliative treatment 
alone is admissible. Insufflation of morphine into the postnasal space 
is the most efficient means of controlling the pain. Insufflations of ortho- 
form powder have an anaesthetic and antiseptic influence. 



DISEASES OF THE PHARYNX 
AND LARYNX. 

BY JAMES E. NEWCOMB, A.B, M.D, 

Instructor in Laryngology, Cornell I'niversity Medical College, Xew York City. 



DISEASES OF THE PHARYNX. 



CHAP TEE I. 
ANATOMY 'and PHYSIOLOGY OF THE PHAEYXX. 

The pharynx extends from tlie base of the skull as far down as the 
lower border of the sixth cervical vertebra^ where it becomes continuous 
with the oesophagus. Its total length is five inches and its general shai)e 
that of a funnel. The j)ortion particularly considered here is that below 
the level of the soft x>alate. commonly divided into the oropharj-nx and 
the laryngopharynx. The transverse diameter is considerably greater 
than the antero-posterior. During the act of swallowing the soft palate, 
which in repose i)rojects downward and backward into the pharynx, is 
drawn upward and backward so as to shut off the oral portion of the 
cavity from that above, — the nasopharynx. 

The oropharynx extends from the level of the base of the uvula above 
to that of the posterior cornu of the hyoid bone below. This is the por- 
tion observed when the mouth is opened, the latter cavity being separated 
from the pharynx proi)er by a narrow plane known as the isthmus of 
the fauces. Its walls are very pliable, so that its size and shape are con- 
stantly varying. Below the isthmus is the posterior portion of the tongue. 
The isthmus itself consists of a pair of muscles on each side, the palato- 
glossus and the palatoi)haryngeus, which approximate above the soft 
palate but diverge below, the tonsils lying between the two. The former 
X>air are lost on the sides of the tongue, while the latter spread out from 
the posterior cornu of the hyoid bone nearly to the middle line of the 
pharynx posteriorly. The special anatomy of the tonsils, palate, and 
associated structures will be considered later. 

The laryngopharynx is equal in length to the combined nasopharyn- 

463 



464 



DISEASES OF THE PHARYXX. 



geal and oral portions^ and is situated behind the entire extent of tlie 
larynx. In its uj)per anterior wall lies the superior opening of the 
larynx. On each side of this is a longitudinal groove or fossa about one- 
half inch in its an tero- posterior measurement and a little more in its 
transverse, called the ^^ sinus pyriformis/' representing the remains of 
the fourth original cleft. According to Quain, whose description is in 

the main here followed, the 
^^^- ^''^- transverse diameter of the 

pharynx opposite the laryn- 
geal aperture is a little over 
three and a half centimetres. 
Below this level the anterior 
and posterior walls are in 
contact. The transverse di- 
ameter remains fairly con- 
stant until the level of the 
cricoid cartilage is reached, 
where it rapidly contracts, so 
that at its extremity it is only 
about fourteen millimetres. 
At about its middle is the 
level of the epiglottis, while 
anteriorly on either side is 
the upi^er portion of the 
glosso-epiglottic fold extend- 
ing in a general forward and 
downward direction. 

Passing from within out- 
ward, the walls of the phar- 
ynx are found to consist of 
four distinct layers. The 
mucosa is formed of connec- 
tive tissue with low papillse 
and covered with stratified 
epithelium, though the cells 
lining some of the gland- 
ducts show occasional cilia. 
Eacemose glands are numerous, while above lymj^hoid tissue is especially 
abundant. Next to the mucosa comes the i)haryngeal aponeurosis, then 
the muscular coat, and finally another layer of fibrous tissue which 
unites with that covering the buccinator muscle, the combined structure 
being known as the buccopharyngeal fascia. The pharyngeal aponeu- 
rosis is thin and lax below. Posteriorly the buccopharyngeal fascia is 
connected by loose areolar tissue to the prevertebral fascia, covering the 
bony spine with its muscular attachments. 




Side view of muscles of the pharvBx. (Gray and 
Browne.) 1, stylopliaryngeus ; 2, styloid process ; 3, upper 
jaw; 4, pterygomaxillary ligament; 5, lower jaw; 6, hyoid 
bone ; 7, thyroid cartilage ; 8, cricoid cartilage ; 9, left in- 
ferior constrictor ; 10, left middle constrictor ; 11, left su- 
perior constrictor ; 12, trachea ; 13, oesophagus ; 14, naso- 
pharynx ; 15, oropharynx ; 16, laryngopharynx. 



PLATE YITT. 




- 14 



Median stction of the head and neck. (Quain, after Braune.) 1, sphenoidal sinus ; 2, lateral recess 
of pharynx ; 3, pharyngeal orifice of Eustachian tube ; -1, anterior arch of atlas ; 5, soft palate ; 6, body 
of axis ; 7, oral portion of pharynx ; 8, epiglottis ; 9, arytenoid muscle ; 10, cricoid cartilage ; 
11, trachea; 12, oesophagus; 13, origin of innominate artery from aorta; li, genioglossus muscle; 
15, geniohyoid muscle ; 16, mylohyoid muscle ; 17, platysma ; IS, hyoid bone ; 19, thyroid cartilage ; 
20, cricoid cartilage ; 21, isthmus of thyroid body ; 22. sternohyoid ; 23, sternothyroid ; 24, left innomi- 
nate vein ; 25, manubrium sterni. 



PLATE IX. 





View of the soft palate and isthmus faucium from before. (Quain, after J. Symington.) 1, soft 
palate ; 2, its raphe ; 3, uvula ; 4, anterior, and 5, posterior pillar of fauces ; 6, tonsil ; 7, posterior wall 
of pharynx ; 8, dorsum of tongue. 



ANATOMY AND PHYSIOLOGY OF THE PHAEYNX. 465 

The muscles of the pharynx are longitudinal and constricting. The 
former are the styloi^haryngeus and palatopharyngeus on each side. Into 
the median pharyngeal raphe are also inserted the constrictor muscles, 
called respectively superior, middle, and inferior. The superior arises 
from the hamular process of the j)terygoid plate of the sphenoid (j^tery- 
gopharyngeus). from the mylohyoid line on the inferior maxilla (inylo- 
2)]iaryngeus), from the side of the tongue {gJossopliaryngeus)^ and from the 
buccopharyngeal fascia (huccopharyngeus) ; the middle, from the greater 
cornu of the hyoid bone (keixitopharyngeus) and from the lesser cornu (cJion- 
dropharyngeus) ; the inferior, from the outer surface of the thyroid carti- 
lage (thyrophayyngeiis) and from the cricoid cartilage (cricopJmryngeus). 
All of the foregoing receive their nerve-supi^ly from the glossopharyn- 
geal trunk and from the pharyngeal plexus. Their lymj)hatic drainage 
passes eventually into the sui)erior deep cerA^ical glands. The blood- 
supply is very abundant, the vessels entering into it comj^rising the ton- 
sillar and palatine branches from the facial artery, the descending palatine 
from the internal maxillary, ascending pharyngeal, and dorsalis linguae. 

Development of the Pharynx. — From a developmental point of view 
the i)haryux is to be considered as the upper jDart of the alimentary 
canal. In mammals this extends from one end of the embryo to the 
other, below the vertebral axis i)resenting a manifest division into three 
parts. One of these occupying the embrj'onic part enclosed by the 
cephalic fold is named the foregut, being merely the upi)er part of the 
canal formed by the inflection of tlie hypoblastic layer of the original 
membrane, which sui)x)lies the ei^ithelial lining of the i)rincipal cavities. 
The pharynx, then, is merely the enlarged cephalic portion of the foregut. 
The mouth proper is no part of the primitive alimentary canal, but is 
formed by an involution of parts of the face, and receives its lining 
membrane therefor from the epiblast. It is separated for a time from the 
pharynx by reflection of the blastodermic layers, but communication is 
finally established by a solution of coutinuity of these layers. This 
septum between the foregut and stomodceum, as the mouth involution is 
called, is manjifest in the human embryo as early as the twelfth day, and 
the disappearance of the septum occurs soon after. 

Anatomy of the Soft Falate. — The soft palate is the musculo-aponeurotic 
curtain which projects downward and backward into the pharynx from 
the posterior border of the hard palate, — that is, the posterior edge of the 
horizontal portions of the palate bones. It is covered with mucous mem- 
brane continuous with that of the surrounding parts. From its middle 
hangs a fleshy projection, the uvula, which is composed mainly of the 
azygos uvulie muscle, formed by the union of two symmetrical strips or 
bundles of fibres which arise, one on each side of the median line, from 
the tendinous structures of the soft, and occasionally the middle of the 
posterior border of the hard, palate. The sides of the base of the soft 
palate gradually extend down into the two pairs of muscles known as the 

30 



466 DISEASES OF THE PHARYNX. 

faucial pillars, to which reference has already been made. In the soft 
palate also terminate two other symmetrical muscular bundles on each 
side. These are made up of the levator palati, arising from the petrous 
portion of the temporal bone in front of the orifice of the carotid canal, 
and from the cartilaginous portion of the Eustachian canal, passing down- 
ward and forward and inserted into the posterior surface of the soft pal- 
ate, and the circumflexus or tensor palati, arising from the navicular 
fossa at the foot of the internal pterygoid plate, from the outer surface of 
the Eustachian canal, from the spine of the sphenoid and the edge of the 
tympanic plate of the temporal bone, passing downward on the internal 
pterygoid plate between it and the muscle of the same name. It ends in 
a tendon, which passes around the hamular process, where a synovial 
bursa smooths its passage horizontally inward, and terminates in the 
fore part of the aponeurosis of the soft palate and the under surface of the 
palate bone. 

The innervation of the palatal muscles is undoubtedly from the vago- 
spinal nerve, though this view is opposed to the older teaching. Turner ^ 
believes that the nuclei of origin of both the bulbar nerves — glosso- 
pharyngeus and vagus — are really parts of one mixed nerve, having a 
dendrite nucleus of origin of their efferent (motor) fibres. This is called 
the nucleus ambiguus. From its lower end the lowermost of the vagal 
root-fibres emerge, and passing into the trunk of the vagus nerve are given 
off by the pharyngeal branches to the pharyngeal plexus, from which 
they are distributed to the levator muscles of the palate. 

Fhysiology of the Fharynx and Soft Folate. — Leaving out the naso- 
pharynx, it may be said that while the rest of the cavity is a common way 
for both air and food, it properly belongs to the digestive rather than the 
respiratory tract. During deglutition the larynx is drawn upward and 
forward by the muscles attached to the hyoid bone and by the stylo- 
pharyngeus so as to be both closed by the epiglottis and overlapped by 
the tongue. At the same time the palatoglossus muscles constrict the 
fauces, and so shut off the bolus from the mouth. The forward and up- 
ward movement of the larj^nx is of more importance than the '' cover- 
lid" action of the epiglottis, for the removal of the latter from animals 
does not prevent them from swallowing without difficulty. A like favor- 
able result remains after the destruction of the cartilage by various ulcer- 
ative processes. An additional safeguard against the entrance of food 
into the air-tube is found in the sphincter-like action of the muscles which 
surround the top of the larynx. The voluntary part of the process now 
ceases and the involuntary begins. The soft palate being made tense 
by the action of its superior muscles, the palatopharyngei are approxi- 
mated, the uvula being between, and thus prevent the ascent of the 
bolus into the nasopharynx. They also bring the posterior wall of the 

^ Laryngoscope, 1898, vol. v. p. 33. 



ANATOMY AND PHYSIOLOGY OF THE PHARYNX. 467 

pharynx somewhat forward, and in this manner guide the bolus into 
the lower pharynx. It now meets the action of the constrictors, which 
by their vermicular movement from above downward guide it into the 
oesophagus. 

It is thus seen that the action of swallowing is a complex one, and if 
there is any interference with the harmonious action of the vaiious mus- 
cular structures there is a liability of the passage of ingesta into the 
nasopharynx {e.g.. diphtheritic paralysis) or into the larynx {e.g., bulbar 
paralysis). 

The faucial structures are also concerned in articulation. The lungs, 
acting as a bellows, force aii' against the vocal bauds, setting uj) vibrations 
which produce the "raw material," so to speak, of articulate speech, 
while its modification into letters and syllables is effected by the varying 
movements of the soft structures higher up. The soft palate hanging as 
a curtain can divert the sound-waves either into the nasopharynx or the 
mouth, thus producing either nasal or oral tones. Pure vowel sounds are 
conditioned tipon the raising of the curtain, while consonants require the 
interruption of the sound-waves by the parts anterior. — e.g.. tongue, 
teeth, and lii)S : hence the division of consonants into gutturals, dentals, 
and labials. The proper action of the soft palate also has reference to the 
production of overtones in singing. 

Marian ^ has recently maintained that the soft pahite api^reciates the 
gustatory sensations of sweet and bitter, as tested by solutions of sugar 
and quinine. This is due to the ramifications of fibrils of the glosso- 
pharyngeal nerve on its anterior surface. 

Various functions have been assigned to the uvula. It has been looked 
on as a conductor of the secretions of the parts above and behind to the 
mouth. Some have regarded it as analogous to the weight on a drop- 
curtain, preventing too long contact of the moist soft palate with the pos- 
terior wall of the pharynx. Still another view assigns to the organ the 
role of a pillar to supi^ort the soft palate during phonation, the base 
being the tongue. 

METHODS OF EXAMINATION. 

For the proper inspection of the fauces and pharynx the patient, if 
able to be out of bed. should sit in a straight-backed chair with the 
shoulders slightly backward but the chin a little depressed. For exami- 
nation by direct light the examiner stands a little to one side so as not to 
obstruct the rays from the souitc of illumination. A few patients can 
depress the tongue sufficiently to allow of a fairly good inspection of the 
oroi^harynx, but the helj) of some form of tongue- depressor is generally 
needed, familiar varieties of which are herewith figured. 

Tongue-Depressors. — The use of a particular instrument is somewhat a 

1 L'Echo Med. du Xord, January 28, 1900. 



468 



DISEASES OF THE PHARYNX. 



matter of habit. The Tiirck variety with the curve at the bottom of the 
handle can be held by the patient himself if for any reason the examiner 
requires the use of both hands. The patient having fully opened the 
mouth, the examiner presses the blade firmly though gently down on the 
dorsum of the tongue, care being taken to avoid either pressure or trac- 
tion on its rootj both of which invite gagging. 

As to the source of illumination, sunlight is preferable if it can be 
had, because it best shows the normal color of the parts. If the patient 
is in bed any kind of a lamp can be used, or the simple device of a candle 
backed by the bowl of a large spoon, which makes an excellent reflector. 
The matter of source of light is further considered under ^' Examination 
of the Larynx," where the indirect method of examination by means 
of the head-mirror is explained. 



Fig. 173. 




Method of depressing the tongue for examining the pharynx and for posterior 
rhinoscopy. (Bosworth.) 

The pharynx having been thus exi)osed to view, the physician should 
look for possible vascular changes, swellings, ulcerations, or deposits on the 
various regions of the throat. The gums should be examined for the char- 
acteristic changes of mineral poisons, inflammations, ulcerations of the 
various dyscrasise, and for indications of depraved blood states (scurvy, anse- 
mia, etc.). The uvula and soft palate should be touched with the probe 
(a simple but much- neglected instrument) to determine their sensitiveness 
and motility. According to Lennox Browne, congestion of the anterior 
pillars betokens associated digestive disorders or some dyscrasia, while 
that of the posterior pillars suggests improjper or excessive vocal effort. 



ANATOMY AND PHYSIOLOGY OF THE PHARYNX. 



469 



Certain conditions affecting tlie tongue concern the laryngologist, espe- 
cially the state of the vascular and lymphoid structures at its base. So 
also the condition of the same structures on the posterior pharyngeal wall 



Fig. 174. 






Tongue-depressors. 



should be carefully observed. The conditions to be noted concerning 
the faucial tonsils are spoken of under diseases of those organs. 

To overcome irritability ice- water gargles, weak cocaine solutions, 
etc., may be used, or, in the more obstinate cases, the system should be 
brought under the influence of the bromides. 



CHAPTEE 11. 

MALFORMATIONS AND DEFORMITIES OF THE PHARYNX. 

The various deformities which result from the different specific pro- 
cesses are considered under the respective headings of those affections. 
Congenital malformations occur either as stenoses or pocket -like dilata- 
tions, and are often due to unexplained developmental errors. They 
commonly occur low down in the pharynx proper or at the junction of 



Fig. 175. 



Fig. 176. 




} ' 



"«i? 



^ V 



l^^ 



T^.. 



\ 



.<3 




a 




^,j 



Congenital pouch and atresia of the pharynx. 
(Lennox Browne.) 



J:^ 



Pouch of the pharynx in advanced life. 
(Lennox Browne.) 



the oro- with the nasopharynx. Unless some intercurrent inflammation 
takes place, the patient rarely experiences any inconvenience. At the 
lower site there is sometimes a narrow, annular, perforated septum just 
at the oesophageal junction, with a superjacent stenosis. 

470 



MALFORMATIONS AND DEFORMITIES OF THE PHARYNX. 471 

Traumatic stenosis may follow tlie ingestion of some corrosive poison, 
scalding water or other-fluids (common with children). Stenosis may 
also result from pressure from a retropharyngeal abscess, glandular en- 
largements, or sj)inal disease. 

Pharyxgocele. — A special deformity from dilatation is that known 
as pharyngocele. This is a peculiar diverticulum, due either to pressure 
or traction, though the action of the latter force in the case of the phar- 
ynx has been denied. The pocket is always found at the lower portion 
of the pharynx or at the upper portion of the oesophagus, and is some- 
times lateral, sometimes median. At this site the muscular layer is thin 
and the fibres run in parallel lines. The larger diverticula hang down 
as pouches between the spine and the gullet. The walls are thick and 
firm, and are formed by the bulging of the mucosa between the fibres of 
the musculosa. A sort of adventitious sphincter is found around the 
neck of the sac. Most of the cases are among adolescents, and women are 
rarely, if ever, affected. The cause is often hard to ascertain. The 
sequence of events seems to be as follows : a part of the pharj^ngeal wall 
loses its power of resistance against pressure ; this may result from some 
foreign body remaining in and separating the muscular fibres, as a crust 
of bread, cherry-stone, bone, etc., or there may be a rupture of the mus- 
cular fibres from violence or excessive vocal effort. 

Given from any cause a spot of least resistance, the rest of the pharynx 
acts most forcibly against it. The mucosa bulges, the musculosa yields, 
and thus a sac is formed ; iugesta fall into the latter, and, from a lack of 
corresj)ondence between the axes of the oesoi^hagus and the j)har3^nx, 
very little food enters the latter cavity. 

Sum2)toms. — Inability of the food to reach the stomach soon leads to 
emaciation, but before this stage is reached it will be easy to recognize a cer- 
vical swelling on one or both sides, from which food cau be forced out by 
pressure. A sound passed into the pharynx is arrested by the pocket, 
and it is extremely difficult to make it ^enter the oesophagus. Pressure 
on surrounding structures may cause various disturbances of the circula- 
tory and vascular systems. Later there may be adhesive inflammation of 
the sac to surrounding parts. 

Treatment. — In the earlier stages the patient should be fed on fluid 
diet and through a tube. Electricity may be used to strengthen, if pos- 
sible, the muscular coat. Surgical treatment consists in performing i^har- 
yngotomy and removing the sac from without, and modern surgery has 
recorded many triumphs in this field. The honor of the first successful 
case belongs, I believe, to W. I. Wheeler. ^ 

Defects ix the Faucial Pillars. — Several cases of this nature 
have come under the observation of the writer.^ They are not as un- 

1 Dublin Jour. Med. Sci., 1886, p. 460. 

^ Anatomical Defects in the Faucial Pillars, Laryngoscope, 1897, vol. ii. p. 220. 



472 



DISEASES OF THE PHARYXX. 



Fig. 177. 



common as is generally sui)posedj yet, according to Fincke/ Eosenberg 
found only twenty-five instances out of fifteen thousand patients exam- 
ined, While Fincke himself found only one instance in four thousand 
patients. The anterior pillars are involved in eighty per cent, of the 
cases, and sixty per cent, occur on the right side. Occasionally there is a 
double defect in the same pillar. The gaps are generally oval in shape, 
measuring on the average three by ten millimetres in diameter, the long 
axis of the oval corresponding to that of the pillar. The edges are per- 
fectly smooth and the surrounding mu- 
cosa is normal. 

Cases of this nature fall into two 
categories : first, congenital cases, and, 
second, those due to some destructive 
process. The latter may result from the 
breaking down of gummy deposits, or 
from an opening left after incising a 
phlegmon in this region. The congenital 
cases are now looked upon as incomplete 
closures of the original branchial clefts. 
Other theories are those of Testut, who 
believes that they are due to embryonic 
absorption of tissue previously formed, 
and of Broeckaert,^ who regards them 
as analogous to the partial persistence 
of the x^haryngeal clefts sometimes found 
in the form of fistulse more or less com- 
plete and situated towards the bottom of 
the lateral pharyngeal walls. 

The first case, reported by Wolters in 
1859, ^ was that of an adult male. Both 
anterior pillars presented an hiatus. The 
literature of the subject is then a blank 
until 1878, when a second case of sym- 
metrical defects in the anterior pillars 
was reported by J. Solis Cohen, '^ the patient being a man aged forty years. 
Cohen suggested that the condition was essentially a separate investment 
by the pharyngeal mucosa of the palatoglossus muscles, though he offered 
no suggestion as to the cause of the defect. He adds that caution should 
be exercised not to confound such absence of tissue with the results of 
previous ulceration (Fig. 177). 




Separate mucous investment of the palato 
glossus muscle on each side. (Bosworth.) 



^ Archiv. Internat. de LaryngoL, 1899, vol. xii. p. 233. 
^ Rev. de LaryngoL, 1893, vol. xiv. p. 577. 
s Zeitsch. f. rationale Med., 1859, Bd. vii. S. 156. 
* New York Med. Record, 1878, vol. xiv. p. 44. 



MALFOI?MATIONS AND DEFORMITIES OF THE PHARYNX. 473 

In reiDortiiig six cases, Boucheron^ gives no particulars, except to 
say that lymphoid hypertrophy in the pharyngeal vault was found in 
all. In one case Schrapinger ^ noted a furrow on the upper lip running 
down from the nostril towards, but not quite reaching, the mucocutaneous 
junction. He suggests that there may have existed an intrauterine hare- 
lip, cured before birth. 

A point of considerable interest is the rudimentary condition of the 
tonsils frequently found in these cases. Fowler ^ believes this to be the 
rule. In one of his cases with almost complete absence of the faucial 
tonsils there was a broad band of lymi)hoid tissue, suggesting, he says, 
compensatory hypertrophy, extending across the tongue, api)areDtly (from 
his description) anterior to the lingual tonsil. It has been pointed out, 
however, that rudimentary tonsils are frequently found in persons with 
normal i^illars. In one instance Claiborne * found a supernumerarj^ tonsil. 

All of these cases are, in the main, free from any symptoms ; where 
the tonsils have been wanting there has sometimes been a pocketing of 
soft foods between the pillars. Most of the cases have come to light 
during routine examinations of patients who were in no wise suffering 
from any symptoms referable to the fauces. 



1 Eev. de Laryngol., 1890, vol. x. p. 528. 

2 Monatssch. f. Ohrenh., 1884, Bd. xviii. S. 204. 
=» London Lancet, 1892, vol, ii. p. 1493. 

* New York Med. Jour., 1890, vol. li. p. 147. 



CHAPTEE III. 
ACUTE INFLAMMATIOXS OF THE PHARYNX. 

An explanation of tlie etiology of the acute affections of tlie pharynx 
is found in its double function as food- tube and air- conduit. It there- 
fore shares in the affections of both the digestive and the respiratory 
tracts. Scrofula, gout, and rheumatism underlie many acute outbreaks. 
Being a combination of fibrous aponeurosis, muscle, and mucous mem- 
brane, it naturally shares in the forms of inflammation which affect these 
structures throughout the body. 

Acute Catarrhal Pharyngitis. — This is an example of the sim- 
plest type of an acute inflammation in a mucous membrane, — the exuda- 
tive. 

Etiology. — No age is exempt. Spring and fall (damp days) furnish the 
greater number of cases. Sudden changes of temperature are a prolific 
exciting cause. General predisposing causes include bad general environ- 
ment, poor ventilation, unsuitable clothing, inhalation of noxious fumes, 
and certain occupations attended with much dust or requiring labor in 
high temperatures. 

The pharynx is practically an immense culture-tube for all sorts of 
bacterial growth. Miller ^ has shown that it is the habitat of more than 
one hundred different species of various lower organisms. Under normal 
circumstances they are all harmless. The ^'catching cold" which is so 
often given as the cause of acute catarrhal attacks really means lessened 
resistance of the tissues to germ vitality, and is synchronous with in- 
creased germ virulence 5 it sounds the note of bacterial attack upon the 
mucous membranes. Many cases of acute pharyngitis are referable to 
ingestion of irritant food, alcoholic excess, overuse of tobacco, foreign 
bodies, etc. A disordered stomach and that group of symptoms known 
as a ^'bilious" attack are at the bottom of many cases of this nature. 
The bearing of this fact on the initial therapy is obvious. 

Fatliology. — The disease is a simple acute exudative inflammation with 
its sequences of congestion, swelling, dryness, and later increased secre- 
tion with the customary escape of leucocytes, and in the more severe cases 
the rupture of superficial capillaries and the escape of a little blood. 
The inflammation may be diffused or confined to various sites, such as the 
posterior wall of the pharynx, fauces, or palatal folds. For the latter 
localization the term '^faucitis" is sometimes used. The covering of 
the tonsils is generally affected also. The pharjmgeal mucosa may be 

^ Micro-organisms of the Human Mouth, Philadelphia, 1890. 
474 



ACUTE INFLAMMATIONS OF THE PHARYNX. 475 

simply reddened, or where there is an acute exacerbation of a chronic 
process it may be, in addition, shiny, smooth, or granular. 

Symj>toms. — Initial symptoms may be either local or general. As a 
rule, there is a mild constitutional febrile reaction. Locally there is a 
sensation varying from a mere dryness to a pain of considerable intensity. 
This pain is experienced not alone in inflammations of the pharynx but 
also in those of adjacent areas, notably the nasopharynx and even the 
nose, though it is invariably referred b}^ the patients to the pharynx. 
Swallowing is painful, there is an irritative cough with the constant sen- 
sation as of a foreign body, and thick viscid mucus, sometimes streaked 
with blood, is exi)elled. 

Prognosis. — This is always good as regards the eventual integrity of 
the tissues, for the disease rarely extends to the deeper structures. 

Treatment. — A mercurial should be administered, followed in a few 
hours by a saline, and later by small and alternating doses of belladonna 
and aconite or veratrum. Ice-pellets give much relief to the pain, and 
cold applications may be made to the neck. Weak cocaine solutions are 
also admissible, provided they are used with a graduated atomizer and 
the quantity of the drug employed does not exceed the limits of a safe 
internal dose ; but menthol in albolene, fifteen grains to the ounce, is 
often just as serviceable. During the stage of increased secretion any 
astringent troche may be used. If the stage of dryness is unusually pro- 
longed, tartar emetic, apomorphine, and remedies of that class may be 
given with a view to re-establish the secretion. 

In diathetic cases the salicylates, guaiac, colchicum, and the combina- 
tions of iodine with iron find their peculiar field of employment, and in 
all cases a simple tonic is advisable after the subsidence of the acute 
symptoms. Most cases, however, are in the second stage when they come 
under the observation of the i)hysician, particularly those of a milder type, 
not confining the patient to bed. When the inflammation is confined 
to that part of the i)harynx which comes under immediate inspection it 
is possible to remove the inspissated secretion with some warm alkaline 
spray, as Dobell's solution or that made from the Seller tablet, after 
which astringent solutions should be ai)plied directly to the parts. This 
application may be made by si^ray, brush, troche, or gargle. Nothing is 
gained by the employment of an elaborate formulary of the new and more 
fashionable remedies ; the faithful use of those that are old and tried will 
give as prompt and satisfactory results. Tannin ten grains, with five 
of alum, to the ounce of water may suf&ce. The writer i)refers the gly- 
cerite of boroglycerin in these cases, using it in full strength on an a^)- 
plicator, or, if the mucosa is especially tender, diluting it with a little 
water. Doubtless the good elfects of many solutions are due to their 
antiseptic properties, even though the latter are weak. 

It has become the fashion in certain quarters to decry the use of gar- 
gles. Certainly troches are very much more easil}' handled, but the writer 



476 



DISEASES OF THE PHARYNX. 



does not believe that the day of gargles has entirely gone by. It is alleged 
that they put a strain on inflamed structures, and that the fluid comes 
in contact with only a small portion of the inflamed area, never passing 
beyond the anterior faucial pillars. Every sore throat does not require 
a gargle, but there are many that do. Saenger's contention that but very 
few persons are able to cleanse the parts back of the anterior pillars cannot 
be accepted. The writer believes that the tonsils can be reached by gar- 
gling, except at the extreme upper portion ; some parts of the lateral 
pharyngeal walls can be reached only with the applicator. It is true that 
some patients experience great difficulty in gargling, but in them a spray 
coarse enough to be of any service is apt to cause gagging. 

During the attack the food should be bland and unirritating. Special 
attention should be paid to footwear and underclothing in order to pre- 
vent recurring attacks. The neck and upper chest should be douched 
night and morning with cold water and briskly rubbed with a coarse 
towel. If this latter is done with the body clothed to the waist and with 
the stockings on, there is but little danger of the occurrence of the un- 
pleasant sensations which come from deficient reactive power. 

Acute Phlegmonous Phakyngitis. — In certain cases the inflam- 
mation extends from the mucous membrane into the submucous tissue, 
and is then called phlegmonous pharyngitis. This extension may be 
caused by thermal and mechanical influences, operations, and galvano- 
caastic manipulations. Secondarily it forms a possible feature of various 
acute infections, notably scarlet fever. Some persons are especially liable 
to this variety of pharyngitis, a predisposing cause existing in their low- 
ered vitality. Generally the attack extends to the soft palate and asso- 
ciated tissues. This form is considered under its appropriate heading. 

A rare form of phlegmon in this locality is that known as acute in- 
fectious phlegmon of the pharynx. This disease was first described by 
Senator in 1888. Bosworth (edition of 1892) was able to find records of 
but eleven undoubted cases, so that the lesion must be looked on as one 
of the rare lesions of the pharynx. Dudefoy^ added a few additional 
cases to the list already X3ublished. Still more recently a case has been 
recorded by von Stein, in which death occurred from meningitis and ab- 
scess in the left temporal lobe, being the first fatality from this particu- 
lar complication. ^N'othing is yet positively known as to the exact nature 
of the latter. The disease may be an atypical form of erysipelas. 

FatJwlogy. — The disease is an acute inflammation, generally in the 
oropharynx, which rapidly assumes an infiltrating purulent character 
involving the deeper layers of the mucosa. Bosworth states that the in- 
flammatory infiltrate always remains as such, and never passes to abscess 
formation, at least in the tissue originally affected. Progress is generally 
in a downward direction. Extension to the air-tract is characterized by 

1 These de Paris, 1894. 



ACUTE IXFLAMMATIOXS OF THE PHARYXX. 477 

oedema at all sites where the tissues are of loose formation. The type 
of inflammation is distinctly a septic one. Glands are involved^ and the 
cervical tissues may become so filled up that the hollow between the neck 
and shoulders is quite obliterated. Later any part of the body may 
become the seat of pysemic metastasis. 

Si/mj^toms. — The disease generally begins with sharp pain in the 
pharynx, marked dyspnoea, and intense pain in swallowing, all due to 
the oedematous condition of the structures involved. Pressure over the 
thyroid body causes pain, and this sign is of some diagnostic value.. 
From the outset there is presented the clinical picture of profound infec- 
tion, with fever, delirium, and albuminuria. Of the nineteen cases col- 
lected by Diidefoy, only five recovered. Death followed by inhibitory 
cardiac paralysis even after the air-channel had been opened by trache- 
otomy. 

Treatment — There is no specific treatment. Anti- streptococcus serum 
may be used, but its emj^loyment has not yet been sufficiently extensive 
to allow any definite results to be predicated. The main initial indica- 
tion is to counteract the sepsis by free stimulation, quinine, strychnine, 
control of temperature, and a sui^porting diet. The diffuse infiltration 
renders surgical intervention somewhat indefinite, though there should 
be no delay in performing tracheotomy if the air-passages become ob- 
structed. 

Membranous Pharyngitis. — In many cases there is doubtless a 
membranous deposit on the x^haryngeal walls. Clinically, most cases are 
really true or false dii^htheria, or else the disease assumes a subacute or 
intermittent if not actually a chronic character. More will be said on 
this topic under the heading of chronic pharyngitis. Undoubtedly vari- 
ous bacterial forms are capable of causing an exudate. Glasgow^ has 
reported a case which he considers one of the protean forms of influ- 
enza. His patient was a child aged ten years, who after unusual expo- 
sure to cold was attacked by fever and earache of two days' diu-ation, 
followed by a coryza with a copious discharge of acrid mucus which 
excoriated the skin of the lip. Then came an exudation on the soft 
palate, tonsils, pharynx, and uvula. It was persistently white, much 
elevated, easily detached, and left no ulcer except on the i3alate. The 
skin lesions caused by the mucus were very similar to those on the mu- 
cosa 5 they had, however, raised edges, and the exudate appeared on an 
excoriated base. There was no glandular enlargement, nor was the 
mucosa of the bronchi or of the bowels involved. Aphonia and ui^gent 
dyspnoea were present, due probably to an involvement of the larynx. 
Brandy was given internally with salol and sodium benzoate. Locally, 
hydrogen peroxide was used, followed by boroglyceride applications. 
Convalescence was rapid, though interrupted by a suppurative otitis. 

^ Trans. Amer. Laryngol. Assoc, 1894, p. 124. 



478 DISEASES OF THE PHARYNX. 

Subacute Pharyngitis. — This form of pharyngitis is a clinical 
rather than a pathological variety. Many patients are just on the verge 
of an acute attack. Their voices are husky, they suffer more or less 
from a constant tickling cough, and the muscles of deglutition are hy- 
persensitive, as shown by a frequent desire to swallow. Actual pain is 
rare. As Browne has observed, this symptom varies with the tempera- 
ment of the individual. 

The throat generally shows a patchy redness and an irregular thick- 
ening and swelling of the tissues with more or less of a viscid yellowish 
secretion. Treatment should be commenced with thorough purgation, fol- 
lowed by astringent lozenges or gargles, the latter being especially indi- 
cated if the soft palate is notably affected. These patients should be 
cautioned as to their diet ; care in this respect will generally keep them 
comfortable. Tobacco, alcohol, and all rich foods should be prohibited. 



CHAPTER lY. 
CHROXIC INFLAMMATIONS OF THE PHAEYXX. 

Under this heading may be considered inflammation of the pharyn- 
geal lining as a whole and that subdivision of the process affecting espe- 
cially the lymphoid elements and known as follicular pharyngitis. A 
localized form of the latter is known as pharyngitis lateralis. 

In simple chronic catarrhal pharyngitis the inflammation is, as a rule, 
confined to the pharyngeal mucosa. The u^nila, palate, and faucial pil- 
lars usually escape, though there are cases in which the inflammation 
seems to localize itself in the faucial pillars, these cases being denomi- 
nated chronic faucitis. In patients below middle life enlargement of the 
tonsils is occasionally met with. 

Etiology. — A frequent cause is the continued inhalation of irritants. 
As to the direct effect of tobacco in this class of cases, some authorities 
state that the nicotine and other volatile products set free in smoking 
will set up a chronic pharyngitis from the start, while others maintain 
that these agents merely aggravate pre-existing conditions. The cases 
are apt to be associated with chronic nasopharyngitis, and it may be 
that the constant hawking involved in cleansing the nasopharynx so 
strains the pharyngeal muscles as to aggravate any pre-existing catarrh. 
Also, an abnormal state of the nasal chambers predisposes to this con- 
dition. 

Pathology. — The change may be described as a proliferative inflamma- 
tion occurring in a mucous membrane. The blood-vessels do not take 
any active share in the process except i^resenting in the earlier stages a 
slight hyperaemia. The principal change is the formation of a low grade 
of connective tissue in the deeper layers of the mucosa. In this situa- 
tion the mucous glands are scanty, and those present do not show much 
change. The secretion is apparently increased in amount and is more 
or less viscid. The latter characteristic is not so much an evidence of 
secretion perverted in initial quality as it is that the conditions surround- 
ing the pharj^nx are abnormal, especially with reference to the quality of 
the air passing over it. In some of the long- continued cases enlarged 
veins with nodosities course over the surface. 

Symptoms. — The close relationship of the affection to gastric disorders 
often makes the special symptoms of the latter the most annoying feature. 
These consist of morning retching, nausea, and occasional vomiting, 
together with a continual irritation in the pharynx, which is increased 
by swallowing highlj- seasoned foods and hot drinks. Actual odynphagia 
is rare. The whole lining of the pharynx is extremely sensitive, and it is 

479 



480 DISEASES OF THE PHAEYXX. 

often impossible to make any satisfactory examination at the first sitting. 
The mucosa is of a dark red and beefy color, which, however, as a rule, 
does not extend beyond the posterior pillars. The breath is sour and 
offensive and the tongue more or less coated. The grade of severity 
of symptoms is often conditioned by the amount of accompanying naso- 
i:)haryngitis. If the latter is considerable, the peculiar color of the mu- 
cosa is not limited by the posterior pillars, but is more or less diffused 
over the soft palate. Occasionally a superficial vessel may rupture and 
slight bleeding occur. 

Treatment. — This should be first directed towards the correction of any 
vicious habits in eating and drinking, while the pharynx may for a while 
be best let alone. Weak cocaine solutions may be used to facilitate 
examination, but, if used in spray, the amount of the drug must not 
exceed that of a safe internal dose, for some is bound to be swallowed. 
In some cases it is necessary to put the patients on an ice- water gargle or 
one of the bromides, the latter being swallowed after being gargled, so as 
to reduce the general reflex irritability. During treatment, tobacco, alco- 
hol, coffee, and tea should be cut off ; particularly does this latter apply 
to institution patients, whose tea is almost always a strong tannic brine. 
Salines and cholagogues, alkalies with bitters, find here api)rox)riate 
employment. Greasy foods and pastries fall under the ban. Directions 
should be given to insure proper mastication of food ; heuce little fluid 
should be taken at meals. 

Many cases will be greatly relieved if not entirely cured under such a 
plan . Should the symptoms persist after the stomach is regulated, the 
nose must be looked after and existing abnormalities removed. For 
direct application to the jDharynx, solutions of silver nitrate not exceed- 
ing twenty grains to the ounce, or the zinc salts in the same strength 
(excepting the chloride), may be used on a cotton carrier, though alum- 
nol in a little stronger solution is preferred by many. The writer has 
employed with satisfaction, as a menstruum for the ordinary list of 
topical agents, zinc oleostearate, which is a combination of zinc stearate 
with benzoiuated albolene. It is a viscid, whitish mixture of rather 
agreeable taste, and insures as long a contact of the medicament with 
the tissues as is possible under the circumstances. 

CiiROisric Membranous Pharyngitis. — Cases are seen from time to 
time which i^resent recurring membranous deposits in the pharynx and 
fauces. It may not be quite correct to call them chronic cases, but the 
symptoms never assume the type of acute inflammations. In this cate- 
gory falls the group of cases which have been reported as due to the 
bacillus of Friedlander. This germ has been found in antral pus, sup- 
purative rhinitis, ozsena, rhinoscleroma, and various other conditions. 
In all cases the distress is very slight, often bearing no relation to the 
extent of the membranous deposit, which is apt to be persistent. Glandu- 
lar swelling and fever are absent. The membrane is of a pearly white 



CHROXIC IXFLAMMATIOX'S OF THE THARYXX. 481 

color, very adherent, and on detacliment leaves a bleeding surface. The 
mild tj'x^e of symptoms makes the cases of clinical rather than of i)atho- 
logical importance, if the danger of their j^resence in other conditions 
be excepted. The cases evidently get better by limitation, as no thera- 
peutic measure has proved of any avail. 

Cheoxic Follicular Pharyxgitis. — This form of disease is prac- 
tically confined to the mucosa of the pharj nx proper and does not affect 
the faucial structures. As its name signifies, the brunt of the patho- 
logical change falls upon the lym^^hoid structures which are found in 
the deei^er layers of the mucous lining. The clinical imiDortance of the 
condition lies in the fact that the symptoms are comparatively severe in 
view of the mild api^earance of the lesion, this severity depending on the 
iiivolvement, in some way not yet clearly understood, of the sensory 
nerve-fibrils supplying the affected area. 

Etiology. — The causes of this form of phar^^ngitis include the action of 
that diatliesis which is called lymi)hatism, or the tendency of all the lym- 
X)hatic structures to take on an overgrowth at an early period of life. 
This condition corresponds to the ' ' scrofula' ' of the early writers. While 
hardly admitting the identity of the two, there is no disposition to deny 
their relationship. The lymphatic overgrowth begins in early childhood, 
affecting to a A^arying degree all the lymphatic structures in the region 
of the pharynx and nasopharynx ; but in the earlier years the sj^mptoms 
referable to the latter area predominate, while those attributable to the 
follicular change in tlie pharynx show themselves at a later age. A pre- 
disposing cause is bad hygiene in its broadest sense. Eheumatism and 
gout cannot be regarded as direct causative factors, though persons sub- 
ject to these maladies frequently have sore throats. In the granular 
sub-variety (see below) exacerbations are often referable, according to 
Marage,^ to a hyperacidity^ of the system, as shown in the urine. 

According to this view, granular pharyngitis is nothing but the local 
exi>ression of a general diathesis. It occurs because there is a general 
diminution of the mucous secretions in consequence of their acidity. 
The mucin precix:)itated by this acidity obstructs the mucous follicles, 
thereby preventing them from proi^er function. Gastric aciditj' is also 
increased, so that patients often eat more than they really need, and un- 
less self-restraint is exercised they speedily suffer from dyspepsia. Con- 
cerning the foregoing view, it maj^ be said that Marage evidently had 
in mind a condition different from that generally called pharyngitis 
granulosa. Most authorities place this under the heading of follicular 
pharyngitis, which has nothing to do with the mucous glands. Bosworth 
does not believe that the follicular condition ever develops from an ante- 
cedent catarrh, though Lennox Browne and Kendal Franks have both 
asserted the contrary. 

^ Archives Iiiternat. de LaryngoL, 1900, vol. xiii. p, 30. 
31 



482 DISEASES OF THE PHARYNX. 

The condition is often called ^' clergyman's sore throat," suggesting 
that among the list of causes must be included improper vocal effort. 
This has reference not alone to overforcing of the voice but to its use 
under unfavorable conditions, such as speaking when the throat is in- 
flamed, voice-use by venders in the noise of the streets, by hucksters in 
all sorts of weather, etc. Political orators suffer from this form of throat 
trouble, especially as most of them are utterly deficient in the art of con- 
serving their vocal energies, and are obliged to speak again before the 
fatigue of a previous effort has been recovered from. The voice muscles 
must have i^eriodical rest like other organs. Seller has described this 
fault as a ^^ repeated transgression of the normal registers of the voice." 

17 .^o Fig. 179. 

Fig. 178. __ 




Follicular pharyngitis, with adherence of pillars Large follicles on pharyngeal wall. Dilated 

to faucial tonsils. (Kyle.) vessels with enlarged and adherent tonsils. 

(Kyle.) 

Fathology. — The follicular process is distinct from the beginning^ 
though it may be accompanied by a simple superficial catarrh. The pro- 
cess may take the form of a universal diffusion over the pharyngeal wall; 
thus presenting a finer or coarser granular appearance, or may assume a 
localized form behind the i)OSterior faucial pillars, appearing as ridges 
or bead-chain-like deposits. These ridges are at times ai)parently fused 
with the pillars themselves, though of a darker color. In some cases 
of the latter character, described by Schmidt^ as ^'pharyngitis lateralis," 
this chain of enlarged follicles has extended down the pharyngeal wall as 
far as the epiglottis. This variety is called by Heryng the hypertrophic ; 
he also maintains the existence of another form which he calls the hyper- 
plastic, asserting that an actual formation of new connective tissue is 
found in it, though the situation and gross appearance may be the same 
as in the more common variety. Either form is easily made out on in- 
spection. The affection of the follicles is most marked near the mouths 

1 Deut. Archiy f. Klin. Med., Bd. xxvi. S. 421. 



CHRONIC IXFLAMMATIOXS OF THE PHARYXX. 



483 



of the muciparous glands. The process may be described as a true 
hyperj^lasia, an actual increase in the number of the Ij'mphoid elements, 
especially about the efferent channels of the lymph- nodes. This hyper- 
plasia may be diffused through the deeper as well as the superficial lym- 
phatic structure of the mucosa, causing a general thickening, or it may 
appear as blunt masses projecting but slightly from the surface. In the 
earlier stages these masses have a soft consistency, but in later years 
they grow smaller and harder, and may even entireh^ disapijear. Their 

Fig. 180. 
















-<.^^ 
& 

w^^^ 
W 



Pharyngitis granulosa, (Seifert and Kahn.) 



persistence is the legacj^ of the changes which were set up during the 
period of lymphatism. 

Sym2)toms. — The most i^rominent symptom is a disturbing pharyngeal 
sensation, which may be called ••dyssesthesia'' of the i^harynx. This is 
due to the unusually rich nerve-supply of the pharyngeal mucosa and 
also to the fact that the nerve-endings are involved in the hyperplastic 
nodal changes. It varies from a mere uneasiness to an actual pain, and 
excess of vocal effort aggravates the discomfort. Swallowing is often 
painful. The abnormal sensations have been looked upon as true neu- 
ralgic pains due to increased circulatory activity through the follicles. 
Secretion is not, as a rule, increased, though it may be blood-streaked from 



484 DISEASES OF THE PHARYXX. 

mixture of a superficial vessel. Sometimes the follicles appear to lie on 
a bed of whitish connective tissue, and the whole area seems very dry. 
This is the '^ pharyngitis sicca" of some writers. It must he added that 
many authors regard the latter condition as a distinct form of pharyn- 
gitis without any true inflammatory element and due directly to trophic 
changes, continued irritation, or venous engorgement. The voice is of a 
husky character, probably from a reflex influence upon the muscles of 
phonation, and a dry, nervous cough gives more or less annoyance. 
From time to time the severity of the symptoms will vary according to 
the variable neurotic factor in each individual. 

Associated with the foregoing an elongated uvula is frequently found, 
especially in connection with a chronic pharyngitis. The faucial and 
lingual tonsils are often enlarged, the former adhering to the pillars. 
Enlarged veins may course over the pharyngeal wall, though this is not 
an essential feature of the condition. The disease may continue indefi- 
nitely, remaining localized, but there does not appear to be any conclu- 
sive evidence that it iDredisposes to tubercular infection of the upiDcr or 
lower air- tracts. 

Treatment. — In regard to general measures, the same plan may be fol- 
lowed as suggested under the heading of simple chronic pharyngitis. 
The local treatment consists in the removal or destruction of the enlarged 
follicles, and for this puri30se all sorts of caustics have been used, nitric, 
chromic, trichloracetic acids, the actual and electro -cautery, and for the 
larger hypertrophic and hy]3eri)lastic masses the knife. An amjply suf- 
ficient method of cauterization, if one has not the more elaborate appa- 
ratus at hand, is to use as the destructive agent a small iron wire heated 
in the flame of a spirit-lamp. The wire (of the size of a knitting-needle) 
should be heated to a dull red and thrust directly into the follicle. If 
the masses be broad the wire can be bent, and its surface rather than its 
point used in a similar manner. The ease of manii)ulation of the gal- 
vano-cautery makes it the ideal agent. Six or eight punctures at difl'er- 
ent sites can be made at one sitting, and the injection, by means of a 
curved needle, of a drop or two of a two i^er cent, solution of cocaine 
into each field of puncture renders the latter j^ainless. In any event, it 
is not much more painful than the needle itself, so that many operate 
without the cocaine, on the x)rinciple that one puncture is better than 
two,— one for needle and one for cautery. Eeaction is not, as a rule, 
severe ; it is more pronounced on the lateral than on the central areas of 
the pharyngeal wall. The minute slough comes away in five or six days. 

For the larger masses Stoerk, and more recently Emil Mayer, have 
recommended thorough curetting of the entire diseased area at one sitting. 
Bleeding is slight. In some instances a lymph exudation forms, but this 
generally disappears in a few daj^s, while pain rarely lasts more than 
twenty-four hours. Mayer found that no cicatricial tissue resulted, and 
that the curetting was not attended with danger to healthy tissue. 



CHROXIC INFLAMMATIONS OF THE PHARYNX. 485 

As regards internal remedies, the use of potassium iodide in small 
doses is advised, and tlie employment of various mineral waters, tlie con- 
tinuous current, etc., may be of indirect service in improving the general 
nerve-tone, on which depends the severity of the symptoms ; but such 
measures can hardly affect the local hyperi^lastic changes. Most writers 
insist upon the interdiction of tobacco and alcohol. Bos worth is dis- 
posed to be somewhat more lenient as to alcohol in moderation, though 
he coincides with the majority as to the baneful effects of tobacco on 
catarrhal conditions of the upper air-tract characterized by lymphoid 
hypertrophy. Whenever a cure of the follicular trouble has been ef- 
fected, tobacco may be resumed in moderation. In neurotic i:)atients the 
use of strychnine, arsenic, phosphorus, etc., together with cod-liver oil 
and hypophosphites, is of great advantage. 

Eeteopharyngeal Abscess. — This is a condition frequently over- 
looked, but one always to be borne in mind whenever a child comes 
under observation suffering from difficulty in breathing and swallowing 
without obvious cause. Its im]3ortance is owing to the fact that rwp- 
ture may prove quickly fatal from aspiration of the pus into the lower 
air-tract. 

Eecent anatomical studies by Charpy and Escat show that there is be- 
hind the pharynx and oesophagus a flat shallow cavity, limited behind 
by the aponeurosis covering the spine and in front by a sheath of connec- 
tive tissue. Tlie lateral boundaries are partitions from the lamellar 
sheath to the aponeurosis just mentioned. The cavity reaches above to 
the basis cranii and below to the mediastinum, and its contents are cer- 
tain sympathetic ganglia and lymph-nodes. Into the latter drain the 
lymph-channels of the neck, nasoi^harynx, and pharynx. External to 
its lateral boundaries are imi^ortant vessels and nerves. It is in this 
space that the abscess forms. 

Etiologij. — As a rule, inflammation begins in the lymj^h-nodes and ex- 
tends to the cellular tissue, but it may begin in the latter if there has 
been any trauma, as from instrumental irritation or a foreign body. 
Any infection may set up an abscess here ; hence in children, in whom 
the condition is far more common than in adults, the exciting causes are 
infectious maladies, erysipelas, acute inflammation of the pharynx or of 
its lymj)hoid deposits, otitis media, etc. In one case (Liebert's) the con- 
dition was ascribed to an antral empyema, for as soon as the latter was 
cured the retropharyngeal abscess disappeared. A predisposing cause, 
as diminishing the power of resistance to infection, is found in impaired 
nutrition, especially that referable to syphilitic, tubercular, and lymphatic 
diatheses. W. P. Xorthrui) reported to the New York Pathological 
Society ^ a case with tubercular meningitis and calcareous bronchial nodes. 
The patient was a boy aged three years, without any ante-mortem trace 



1 Cf. Sajous's Annual, 1891, vol. iv. E. p. 3. 



486 



DISEASES OF THE PHARYNX. 



Fig. 181. 



of tuberculosis, yet a tubercular nodule was found in an apparently 
healthy bronchial gland. The case was reported as emphasizing the im- 
portance of searching for latent tubercular deposits and also to call at- 
tention to the fact that the oldest process will often be found in the 
lymph-nodes adjacent to the respiratory tract. 

Pathology. — The process in these cases is one of pus formation, which, 
owing possibly to the proximity of the digestive tract, may be offensive. 
The sac contents are thick and yellow ; the abscess may be in the middle 
line or, if high up, to one side, and burrowing is sometimes extensive. 
The pus-pocket may be unilocular or multilocular. 

Symptoms. — In infants there is a sudden refusal of the breast, with a 
snuffling, metallic cry, possibly dysphagia, and even dyspnoea. In older 

children the usual symj)toms of sore 
throat with febrile reaction are 
found, and in such there is little 
difficulty in making a diagnosis by 
inspection ; but in the youngest pa- 
tients palpation may be necessar}" 
to locate the phlegmon, and the 
mouth-gag should be used if neces- 
sary for careful exploration. A 
soft boggy spot will be felt, in which 
at times a distinct fluctuation can 
be detected. In the most marked 
cases there will be a lateral cervi- 
cal swelling, but no time should be 
wasted in waiting for the appear- 
ance of this feature. There is 
sometimes a forward bulging of the 
soft palate. 

The iDrincipal danger previous 
to rupture is oedema of the larynx 
with displacement of the entire or- 
gan forward, thus causing asphyxia. Eespiration and deglutition grow 
progressively more difficult. Pulmonary complications sometimes arise, 
and infiltration of pus into the cervical tissues may occur, with death 
from septic absorption. The most common danger is that of rupture 
during sleep, in which case the child may speedily be asphyxiated. 

Course and Duration. — These vary greatly. Cases are on record in 
which purulent accumulation has occurred in twenty-four hours, while 
others are prolonged over several weeks or (if tubercular) months. The 
ordinary case comes to a focus in from six to eight days. 

Diagnosis. — Differential diagnosis is required from coryza, the various 
forms of tonsillitis, croup, and even diphtheria. Certain cases in which 
the general symptoms have been pronounced and local trouble slight 




Retropharyngeal abscess, phlegmonous variety. 
(Bosworth.) 



CHROXIC IXFLAMMATIOXS OF THE PHARYXX. 487 

have been mistaken for typhoid fever, but careful examination and jx^j^d- 
tion will generally locate the abscess definitely. 

Treatment. — Immediate evacuation is advised. In an ordinary case 
the child should be held in a good light with opened mouth, and with a 
protected blade an incision should be made from about the middle of the 
sac down to its bottom. The finger in situ guiding the blade should then 
be passed into the incision, thoroughly opening up the sac and thus 
securing comj)lete drainage. Immediately after the primary incision 
has been made the patient should be inverted, so as to allow the sac con- 
tents to drain out of tlie mouth. The incision may be made with the 
head already thrown forward, and the finger will jDrevent the refilling of 
the sac. lugals has reported one case in which, four months after open- 
ing, a fistulous tract was discovered at the base of the tongue, through 
which a small catheter i)assed down, as judged by the x)ain felt, to the 
neighborhood of the right breast, a distance of some thirty centimetres. 
A theoretical danger of opening in the manner above described is that 
of striking the carotid artery, which may be misplaced by abscess press- 
ure ; but, unless there is pressure from the external cervical area, the 
abscess will rather tend to direct the large vessels outward. Piatot has 
recorded one case in which sudden death occurred on making the in- 
cision. Xo oedema of the glottis was present, but the pneumogastric 
nerves had been stretched and pushed back by the abscess. Death was 
ascribed to reflex syncope, though no satisfactory" reason therefor could 
be assigned. 

In cases in which there is much cervical bulging, external incision has 
been recommended. 



Fig. 182. 



CHAPTEE Y. 

VASCULAR ANOMALIES AND PARASITIC DISEASES OF THE PHARYNX. 

An abnormal vascular condition not infrequently seen is that of un- 
usually large and pulsating vessels on the posterior and lateral walls of 
the pharynx. The vessel usually affected is the ascending pharyngeal 
artery, as determined by its position on the superior constrictor and its 
vertical direction. Dissections have shown that when the ascending 

palatine artery is small the ascend- 
ing j)haryngeal is correspondingly 
large, so as to furnish sufficient blood 
to the area supplied. 

Cases of this nature have been re- 
ported by many observers. The con- 
dition is generally unilateral, though 
Farlow has seen two instances of bi- 
lateral enlargement. At times the 
area of pulsation is so distinct and 
localized as to suggest a true aneu- 
rism, but generally the affected area 
is a linear one along the surface 
under the mucosa ; if j)rojecting 
therefrom, it is a knuckle of the ar- 
terial tube bulged out from the natu- 
ral course of the vessel. McBride ^ 
has seen one case in which the pos- 
terior pillars themselves seemed to 
pulsate, but an enlarged vessel was 
found immediately behind, and a systolic bruit was audible. In a second 
case a pulsating mass suspected to be an aneurism proved to be a cyst. 
In a third case the i^atient suffered from a tinnitus compared to the 
hissing of escaping steam 5 in this instance many of the bodily arteries 
visibly x)ulsated, and the right radial ran an abnormal course. In the 
pharynx pulsation was visible on both sides at the junction of the pos- 
terior and lateral walls 5 on the right side the pulsation was communi- 
cated to the tonsil. 

In other instances, such as that reported by A. Brown Kelly, the 
pulsating vessel has been regarded as an abnormally tlexuous internal 
carotid bulging towards the posterior pharyngeal walL Of course, an 




Ascending pharyngeal arteries of abnormal 
size. (Farlow.) 



1 Edin. Med. Jour., December, 1896, p. 510. 



488 



VASCULAR ANOMALIES AXD PARASITIC DISEASES. 489 

aneurism may occur, as in Eicliardson's case,^ in which the swelling ex- 
tended from a point a little to the right of the median line to the lateral 
wall of the pharynx, and from the level of the base of the tongue to 
that of the lower edge of the i^alate. A bruit was audible, disappearing 
under pressure on the common carotid. Eosenthal"^ rex)orts a case of true 
aneurism the size of a coffee bean located at the origin of the right 
pharyngopalatine i)illar. Pulsation ceased on comj^ression of the right 
carotid. TJhl ^ has seen one case of traumatic aneurism of the descending 
palatine. 

In addition to pulsating arteries, j^ulsatiug veins have been noted by 
Sanderson and Cresswell Baber. Xormally there exists on the posterior 
and lateral pharyngeal walls a net-work of veins with meshes of unequal 
size, the principal channels of which empty into the internal jugulars and 
communicate posteriorly- with the pterygoi")alatine vessels and median 
and posterior meningeals. This plexus is the terminus for the numerous 
veins coming from the muscles. According to Bimar and Lapeyre, there 
is at the level of the inferior portion of the i^osterior pharyngeal wall a 
very remarkable deep plexus seen at all ages ; it lies between the mucosa 
and inferior constrictor, partially concealed by the inferior angle of the 
middle constrictor. 

The foregoing are tyjncal descriptions of these cases, many more of 
which might be cited. The writer has seen several such, and nearly 
every year one or two are presented at the section meetings of the Xew 
York Academy of Medicine. In considering this class of anomalies two 
facts should be noted. The first is, that the vast majority of them pre- 
sent no symptoms whatever, and the existence of the abnormality is un- 
known until the i^atients happen, for one reason or another, to undergo 
a systematic examination. The second fact has reference to the possible 
occurrence of alarming, even fatal, hemorrhage from oi)erations per- 
formed under these circumstances. From the site of some of the vessels 
it is evident that the incision for an ordinary quinsy would not be free 
from danger, and the same remark applies with still greater force to the 
removal of lymphoid hypertrophy from the pharyngeal vault. The cau- 
tion is suggested that careful x^al^^ation should in this region i^recede 
every use of the knife. If enlarged pulsating vessels are found, the field 
of operation should be carefully circumscribed, and it may be that oper- 
ative intervention is entii^ely out of the question. 

Hemorrhage from the Pharyxx. — Hemorrhage from the pharynx 
may arise from three sets of causes. 1. Trauma, as from a foreign body, 
surgical procedures, violent hawking, etc. 2. Changes in blood com- 
position, and possibly in the vessel -walls themselves, which permit 

^ Jour. Am. Med. Assoc, August 2, 1S90, p. ISO. 
^ Rev. de Laryngol., 1896, vol. xvi. p. 1185. 
3 Miinch. Med. AVochen., May 21, 1895, S. 495. 



490 DISEASES OF THE PHARYNX. 

of leakage in different areas of the body ; under this heading are in- 
cluded hsemophilia, leukaemia, pernicious ansemia, iDurpura, scurvy, etc. 
3. Ulcerations of various kinds, suppuration, and possibly varicose veins ; 
this heading includes cancerous and other malignant ulcerations and that 
dry form of catarrh in which the formation of crusts with subsequent 
dislodgement may cause the erosion of superficial vessels. Pharyngeal 
hemorrhages from the causes enumerated under the second heading are, 
with the exception of scurvy, rare. Tubercular and syphilitic ulcera- 
tions of the pharynx seldom cause bleeding, though traces of blood from 
some other site may in these conditions occasionally be found on its 
walls. G. E. Brewer ^ has reported a case with fatal result in a vigorous 
young man, the bleeding apparently being caused by the rupture of a 
small abscess on the posterior wall of the soft palate. 

Additional importance attaches to the question of hemorrhage from 
the pharynx when it is remembered that patients always suspect lung 
disease when blood comes up from any part of the throat. If examina- 
tion of the lungs, heart, and large vessels reveals nothing abnormal, 
physicians themselves often refer the bleeding to the general indefinite 
region of the throat and regard the matter as of minor importance. Such 
reasoning is superficial and may result in great harm to the patient. In 
the first place, true pharyngeal hemorrhages are rare, and are not to be 
assumed as existing unless a clot or bleeding-point on the surface of the 
mucosa can be located. In the second place, later and more thorough 
examination of a case of 'Hhroat hemorrhage" often discloses some 
serious chest condition. The initial bleeding has probably come from 
some point below the glottis, — that is, it signifies lung disease whether 
or not there are other symptoms to correspond with it. All such cases 
should carefully be followed up. 

A careful search in the mouth and gums for incipient valvular trouble 
without a murmur must, of course, be made, allowing for a temporary 
pulmonary hyj)er8emia. In certain cases the blood escapes by diapedesis 
rather than by actual rupture of vessel-walls, and in this connection 
it may be well to caution the j^rofession against malingerers, who for 
various purposes can bring on pharyngeal hemorrhage with the greatest 
ease. 

Another point to be taken into account is the intimate anatomical 
and physiological relations of the pharynx to the larynx and parts below 5 
under these conditions blood effused in one place may quickly deposit 
itself in another. Care must, therefore, be exercised in deductions as to 
tne actual source of the hemorrhage. Blood effused high up may get 
down into the lungs, and by its action there predispose to later tubercular 
invasion. 

Il^atier'* has endeavored to make a separate division of pharyngitis, — 

^ Yale Med. Jour., 1898. ^ La France Med., August 4, 1893, p. 481. 



VASCULAR ANOMALIES AND PARASITIC DISEASES. 491 

tlie hemorrhagic, — but all the causes in the list of cases given by him can 
be brought under one or other of the forms of pharyngitis. 

Treatment. — The treatment of the foregoing line of cases consists 'in 
the api^lication, if possible, of some coagulating agent directly to the 
point of bleeding when this can be located. Cocaine and suprarenal 
solutions may be used, followed by antipyrin in four per cent, solution, 
and later by a styptic, such as silver nitrate, or even the cautery at a dull 
red heat. Ice-pellets may be held in the mouth, and the familiar gargle 
of Mackenzie (gallic acid one part, tannic acid three parts, water four 
parts) slowly sipped. These measures will generally prove efficient. The 
condition of the kidneys should be looked after, for a coexisting albumi- 
nuria gives a clew to the real source of the trouble. Food should be 
bland and unirritating, and for the first twentj'-four hours after the oc- 
currence of the bleeding all hot ingesta should carefully be avoided. 

PARASITIC AFFECTIONS OF THE PHARYNX. 

The parasites most commonly found in the pharynx and adjacent 
areas are the oidium albicans, actinomyces, aspergillus fumigatus, bacillus 
fasciculatus, — the growth causing that rare affection known as nigrities 
lingure, or ''black tongue,'' — and the different varieties of leptothrix. 
The pharynx is rarely affected alone, but shares in all the mycotic affec- 
tions of the buccal cavity. In this chapter but two conditions are spoken 
of, — thrush caused by the oidium albicans, and leiDtothrix mycosis. 

Thrush. — In young children thrush often affects the soft palate and 
the posterior pharyngeal wall, and is generally a manifestation of some 
acute or chronic digestive disturbance. In adults thrush is rarely seen 
except in wasting maladies running a long course, and even here only in 
severe tj^pes of the various affections, though it may occur in acute pneu- 
monia. Damaschino and others have reported a series of tyi^hoid fever 
cases in which the thrush seemed to assume the character of an epidemic. 
Duguet (quoted by Schech) states that in children the affection spreads 
from the mouth to the pharynx, while in adults the reverse coui'se is fol- 
lowed. This, however, is a matter of minor imi^ortance. 

Oidium. — The oidium is a genus of hypomycetous fungi (naked spores 
or i^rominent threads) the species of which are now regarded as transi- 
tional forms of other fungi. The special one concerned in the production 
of thrush (muguet) is the albicans, the filaments and spores of which 
make up the white patches or coatings on the mucosa. 

Si/m2)toms. — The sym]3tomsof this form of parasitic disease, apart from 
those of the general condition with which it is associated, are generally 
limited to a feeling of discomfort in the throat, though in some cases there 
are burning and lancinating pains and nausea. Children occasionally find 
difficult^" in the swallowing and regurgitation of food. Inspection read- 
ily reveals the local condition, though the microscox^e may be necessary 
to positively assure one's self of the identity of the fungus present. Ee- 



492 



DISEASES OF THE PHARYNX. 



moval of tlie mass is somewhat difficult, in spite of the superficial nature 
of the deposit. In some instances the mycelial threads of the parasite 
penetrate not only the epithelial layer of the mucosa but actually pierce 
it, and reach even the subjacent muscular layers. A little bleeding 
generally follows its removal, and shedding of the epithelium together 
with superficial erosions have been observed. 

Under the microscope the mass removed shows various epithelia and 
schizomycetes and numerous filaments of the oidium albicans, unequally 
jointed with lateral branches and buds. The filaments show violet- colored 
cavities filled with granules ; their ends are rounded off and covered with 
small bleb-like bodies, and, in addition, close to the filaments are the so- 
called conidia, or fruit 
spores. 

Treatment— The treat- 
ment of this condition 
should be mainly pre- 
ventive, and consists in 
the proper hygiene of 
the oral cavity. In all 
kinds of sickness the 
throat should frequently 
be inspected, and if 
whitish i)atches of any 
kind are found their 
nature should be ascer- 
tained. The patient' s 
general condition will 
be of great assistance 
in arriving at an accu- 
rate conclusion. The 
mouth should always 
be cleansed after taking 
food, and in case the pa- 
tient is not able to rinse it, it should be carefully wiped out with a soft 
cloth over the finger, and moistened with, preferably, some weak alkali, 
such as sodium or potassium carbonate or borax, all in watery solution. 
The addition of honey to the latter nullifies its action, for the oidium feeds 
on sweets. In adults the mouth should first be cleansed with cold water 
and then silver nitrate solution, not exceeding in strength ten grains to 
the ounce, applied. This treatment will generally effect a cure. 

Pharyngeal Mycosis — Mycosis Leptothricea. — In 1873 Frankel 
first observed a fungus producing a pharyngeal affection, to which he gave 
the name of mycosis tonsillaris benigna, and which was called by Heryng 
pharyngomycosis leptothricea. Later observation has shown that not 
only are the tonsils affected, but also the tongue, pharyngeal wall. 




O'idium albicans. (Bresgen.) 



VASCULAR AXOMALIES AXD PARASITIC DISEASES. 



493 



faucial i:)illars, deeper recesses of the lateral pharyngeal folds, epiglottis, 
and, rarely, the nasopharynx, larynx, and nose. The fungus clings to the 
epithelium, and often prefers a healthy to a diseased mucosa. The objec- 
tive appearance is that of whitish or yellowish-white excrescences, either 
soft or of a horny hardness, and often with thorny tufts. They are due 
to the growth of the leptothrix, which is described below. 

Predisposing Causes. — These include previous inflammations and carious 
teeth. The fungous growth frequently follows acute tonsillitis, and has 
doubtless often been mistaken for chronic lacunar inflammation. A 
rheumatic tendency has been observed in some cases, though there is no 
certain connection between the two. This particular x)arasite belongs to 
the normal flora of the healthy human mouth ; consequently any lower- 
ing of general vitality, or any persistent change in the chemistrj^ of the 
oral cavity, may bring about conditions which will allow of an abnormal 
development of this or other parasites. 

The Leptothrix. — The deposits generally appear embedded in the cryx^ts 
of the mucosa covering the tonsils, or on other areas where the crj'ptic 
element of the mucosa is not so pronounced. They project above the 
surface, are horny in consistency, and are removed with difficulty. Some- 
times when not actually embedded thej' seem to cling to the surface like 
lichens. They sometimes appear as isolated deposits of varying size, or 

to another and in- 



running from one tuft 



may be connected by threads 

terlacing like the tendrils of a running vine. 

If a bit of deposit be torn ofi", teased in glycerin, and examined with 
a low power of the microscope, there will be found a mass of epithelia 
(an accidental circumstance) sur- 
rounded by irregular granules in Fig. 1S4. 
which are embedded the spores 
of the various species of the lep- 
tothrix fungus. The general ap- 
pearance of the microscopic field 
is well illustrated by Fig. 184. 
These spores are arranged in 
link-like processes, their ends 
being rounded or club-shaped. 
The latter vary in length, and 
sometimes curl up at the end 
into hair-like filaments. Others 
are like colorless rods, but with 
sharj) dark borders, the centres 

seeming to be full of dark granular matter. Besides these spores there 
are round or oval, highly refractive bodies with dark borders, arranged 
in colonies or placed sei3arately between the branching spores. The 
whole forms a net-work composed of spores and refractive granules. 

Xo one has thus far succeeded in cultivating the fungus outside of the 




Buccal secretion. (Von Jaksch and Cagny.) a, 
epithelial cells ; b, salivary corpuscles ; c, fat-drops ; d, 
leucocytes ; e, spirochseta buccalis ; /, comma bacilli 
of the oral cavity ; g, leptothrix huccalis ; h, i, k, dif- 
ferent forms of funsri. 



494 DISEASES OF THE PHAHYNX, 

human body. As lias been intimated, various species of leptotlirix 
threads are constantly present in the healthy human mouth ; altered reac- 
tion of the buccal secretions, gastric disorders, and deposits of tartar on 
the teeth all seem to favor their development. Leyden and Jaffe ^ found 
them in fetid bronchitis, tracheal ozaena, pulmonary grangrene, rhino- 
liths, tonsillar concretions, and vesical calculi ; also in the tongue- coating 
of low febrile states, in the lachrymal duct, vagina, intestines, and fgeces. 
The majority of the pharyngeal cases reported have been in young 
women. In an analysis of a series of cases Semon ^ found age limits of 
twelve and sixty two, the majority of cases occurring between twenty- 
eight and thirty- four years of age. In any situation the growth may 
preciiDitate lime salts from fluids holding them in solution. 

A different view of the exact nature of this affection was advanced 
by Siebenmann in 1895.^ He believes that Frankel's '^benign tonsillar 
mycosis" should be taken from the category of mycoses and placed in 
that of hyiDcrkeratosis of the mucosa. The views of Siebenmann have 
received the supi)ort of Brown Kelly, who published in 1895 * a series of 
papers forming the most complete treatise on the subject extant. He 
thinks that the keratosis is even more extensive than stated by Sieben- 
mann, and prefers the less special descriptive term ''keratosis pharyn- 
gis." He believes that there is a condition which may justly be called 
benign mycosis leptothricea, but asserts that it is quite distinct from the 
one now bearing that name. 

SymjMms. — The symptoms are local, consisting of a varying degree of 
faucial irritation, cough, difficulty in swallowing, reflex laryngeal pain, 
and the sensation as of a foreign body in the throat : at night the latter 
may feel dry and stiff. Constitutional symjDtoms are rare, though Schech 
noted in one instance fever with general discomfort, prostration, and ano- 
rexia preceding the appearance of the fungus. Frankel has seen one 
case with painful swallowing and swelling of the submaxillary glands. 
Semon records a case in which the uvula and soft palate were congested, 
the former being quite cedematous. Inspection may show the tonsils 
somewhat reddened, their follicles enlarged, and their epithelial coat 
manifestly thickened. 

Duration. — Unless treated, the condition may continue indefinitely. 
Periods of improvement and relapse will succeed one another without 
apparent cause, and climatic changes sometimes lead to surprising 
results. 

Differential Diagnosis. — This must be made from diphtheria, lacunar 
tonsillitis, and tonsillar concretions. As contrasted with diphtheria, 



^ Deut. Arch. f. KUn. Med., No. 2, 1867. 

2 St. Thomas's Hospital Eeports, 1883, vol. xiii. 

3 Arch. f. LaryngoL, 1895, Bd. ii. S. 365. 
* Glasgow Med. Jour. 



VASCULAR ANOMALIES AND PARASITIC DISEASES. 495 

there is generally a persistent discrete arrangement of the patches, neither 
fever nor surrounding inflammation is present, the masses are harder than 
false membrane, and the tongue may be involved. 

In lacunar tonsillitis there are usually marked constitutional symp- 
toms vhich are often out of all proportion to the extent of the lesion 
and signify the absorption of septic material. The mucosa between the 
lacunae is inflamed. The exudate is easy of removal and is not friable. 

Tonsillar concretions contain, as will be seen farther on, a great 
variety of substances, including leptothrix threads, but when the crypt 
containing the concretion has once been cleaned out the latter does not 
readily form again. The mycotic dex^osit, on the other hand, constantly 
tends to recur. 

Treatment. — All dietetic errors must be corrected, the digestive tract 
put in order, and the teeth proi^erly cared for. These measures alone have 
cured several cases in the writer's practice. A change of climate will 
cure some cases which have obstinately resisted all forms of treatment. 

Topical measures include the use of caustics, and for this purj^ose nearlj^ 
every caustic remedy in the Pharmacoi^ceia has been recommended. The 
list includes solutions of zinc chloride, balsam of Peru in alcohol, iodine and 
carbolic acid in glycerin, salicylic acid in alcohol (four ]3er cent.), borax, 
mercuric chloride, chromic acid, silver nitrate, and pyrozone, or the 
caustic solution of hydrogen dioxide. Smoking is credited with having 
cured one case, but it is dangerous to apply solutions of nicotine. Some 
of the larger deposits maj' be removed with forceps. If the process is 
localized on the tonsils, and it is possible to remove these organs entirely, 
this should be done. Salol and the alkalies have been given internally 
on the theory of a rheumatic origin of the affection. 

The weak point with all topical ai^i^lications is that they are, at best, 
superficial in action. ^\Tiatever theory may be entertained of the nature 
of the malady, the physical condition to be treated is that of fungous 
masses growing from depressions in the mucosa, and these should be 
thoroughly extirpated. The best plan is to destroy the roots of each 
deposit by means of the galvano- cautery passed deeply into each crypt. 
The process is tedious, but any less energetic measures will only waste 
time, disapi)oint the iDhysician, and disgust the patient. In cases in 
which the cautery is unavailable, chromic acid fused on the end of a 
probe is the best substitute. 



CHAPTEE YI. 

TUBERCULOSIS, LUPUS, AND SYPHILIS OF THE PHAEYNX. 
TUBERCULOSIS OF THE PHARYNX. 

This is one of tlie comparatively rare nianifestations of tubercular 
infection, and in its primary form occurs in only about one per cent, of 
all cases of acute tuberculosis of the upper air-passages. Eosenberg^ 
found only twenty -two cases out of twenty -two thousand clinic patients. 
Secondary involvement is seen in nearly twenty-five per cent, of all fatal 
cases of pulmonary and laryngeal infection, but statistics vary as to the 
frequency of the secondary form. Levy ^ found seventeen instances out of 
one hundred and sixty-two cases of tubercular disease ; in this group, 
however, eleven presented accompanying laryngeal infection. Yariation 
in figures is not to be wondered at when it is considered that at the time 
the local diagnosis is made it may not be possible to detect the exact site 
of other deposits in the body, although the physician may be reasonably 
confident of their existence. As expressed by Price Brown, the exist- 
ence of the pharyngeal deposit is assumed to indicate the i)resence of gen- 
eral tuberculosis in other parts of the body. That there is such a thing 
as primary pharyngeal tuberculosis is, however, beyond all question. 

As opposed to the rarity of this form of tuberculosis is its virulence. 
Bosworth states that ' ' it would seem that a deposit of miliary tubercle 
in the mucous membrane of the respiratory tract assumes a peculiar 
virulence as the seat of the deposit is in portions near the outer world." 

The uvula and soft palate are the favorite sites of invasion. In four- 
teen cases of pharyngeal tuberculosis studied by Wroblewski, the faucial 
pillars were affected in all and the uvula in ten. In the i^rimary cases it 
would appear that the right side is the one more frequently invaded, but 
the reason for this is unknown : it may be due to peculiarities in lym- 
phatic distribution. The anterior surfaces of the pillars and palate suffer 
most, then the tonsils, posterior pharyngeal wall, and hard palate. 

Much has been written in recent times concerning tuberculosis of the 
tonsils, especially the so-called ''latent" tuberculosis. Euge^ made 
microscopical examinations of the tonsils from seventeen individuals, 
seven of whom had deposits in other organs. In five out of the seven 
tubercle bacilli were demonstrable in the tonsillar tissues. These cases 
had also pulmonary disease. Similarly, Strassmann found bacilli in thir- 

1 Eev. de Laryngol., November 15, 1895, p. 1079. 

2 Denver Med. Times, June, 1896. 

3 Yirchow's Archiv, 1896, Bd. iii. S. 431. 



TL'BEKCULOSIS, LUPUS, AXD SYPHILIS OF THE PHARYIS^X. 497 

teen out of fifteen cases. A fallacy incident to all such statistics is that 
bacilli found under such circumstances may be due merely to surface con- 
tamination rather than to actual infiltration of the tonsillar structure 
by the tubercular process. A more positive method of determination 
is by inoculation experiments ; these have been performed by some ob- 
servers, but not by others, and it is consequently difficult to compare one 
set of statistics with another. Labbe and Levi-Sirugue ^ note that the 
tonsils are almost always infected among phthisical adults, but frequently 
passed over in infancy, even when the infection is general. They 
ascribe this to the fact that before the seventh year the child swallows 
its sputa and does not expectorate. 

This ' ^ latent' ' tuberculosis of the faucial tonsils presents itself under 
no special form ; there is no ulceration, and the enlarged organ passes 
as an ordinary enlarged tonsil. There is little reason to doubt tliat many 
of the cases of enlarged cervical glands seen in children are tubercular in 
nature, the portal of infection having been the faucial tonsils, whence the 
bacilli have been conveyed to the lymph-nodes. So, also, according to 
some authors, the infection may be conveyed to the vertebrce and to the 
lungs by the route of the peribronchial glands. Dieulafoy believes that 
the infection may be arrested in the tonsils, and the case thus recover. 
Lermoyez met with two instances of pulmonarj^ infection which seemed 
to follow operations for the removal of lymphoid hyi)ertrophy in the pha- 
ryngeal vault (adenoids), and Lewin ^ has found tuberculosis in five per 
cent, of all pharyngeal tonsils removed. On the other hand, Jonathan 
Wright ^ reports that he has examined for evidences of tuberculosis fifty- 
four cases of enlarged faucial, fifty-one pharyngeal, and sixteen lingual 
tonsils, and that he has not found in any of them either tubercle bacilli 
or tyi)ical giant cells. In the same article he enumerates what he be- 
lieves to be the fallacies which underlie all the modes of investigation 
hitherto followed in the study of this question. Wj^att Wingrave's expe- 
rience coincides with that of Wright so far as the absence of bacilli is 
concerned. Giant cells were noticed by Wingrave more than once, but in 
the absence of the bacilli he does not accept their presence as evidence 
of true tubercle. 

Etiology and Modes of Infection. — The general causes of tuberculosis in 
the x^harynx are the same as those of the dyscrasise in general. The ex- 
130sed position of these parts would seem to make them a favorite site for 
infection, and the marvel is that they are not more frequently attacked ; 
but there are certain natural barriers against this untoward result. The 
constant movements of mastication and deglutition tend to clean the 
mucosa, and it has been suggested that the buccal secretions possess a 

1 Gaz. des Hop., No. 20, February, 1900. 

2 Archiv f. LaryngoL, Bd. ix. S. 377. 

° New York Medical Journal, April 7, 1900, p. 504. 
32 



498 DISEASES OF THE PHARYNX. 

germicidal power, thus, as it were, rendering the surface of the mucosa 
immune. St. George Eeid believes that the saliva offers a distinct bar to 
the acclimatization of the tubercle bacillus. The mouth is always teem- 
ing with all sorts of bacterial life, and it may well be that the struggle 
for existence of some of the more hardy varieties sets up conditions whicli 
are inimical to the development of tubercle bacilli. As indicated above, 
the attack on the fauces is generally secondary to infiltration elsewhere. 
Here the lymphatics are the channel of infection, but the latter may arise 
from direct inoculation. The theory that inoculation takes place from 
contact with sputa is hard to credit, else the disease would be much 
more common. 

Pharyngeal infection may arise through the blood, — e.g., miliary and 
other forms of tuberculosis through the lymph -glands, though the re- 
verse route is more common, — through the inspired air, and through the 
food, especially milk and flesh infected with bovine tuberculosis. It is 
not necessary that there should be a solution of continuity of the pharyn- 
geal or tonsillar tissues, for, according to Strauss, the bacillus can effect 
an entrance through the epithelium. Kriickman finds that in adults the 
tonsils and cervical glands are usually infected by the bacillus after the 
lungs become the seat of the disease. According to Price Brown, Aber- 
crombie and Gee have reported eases following tuberculosis of the bowel. 

Fathology. — Concerning the gross appearances of tuberculosis of the 
pharynx, Kafeman distinguishes two forms : one is the ordinary miliary 
tubercle, which is distributed over the mucosa, and the other is a papular 
lesion, which may be restricted to one or two small areas, and is espe- 
cially apt to appear on the posterior surface of the soft palate. Both 
show under the microscope a small, round-cell infiltration of the con- 
nective-tissue elements, followed by an extension of the process into the 
vessel-walls, gradually narrowing the lumen. Later endarteritis, oblit- 
eration, cheesy softening, and ulceration follow. According to present 
ideas, tubercle bacilli must be present, but clinically it is difficult, or 
even impossible, to find them in the scrapings from the surface or even 
in bits of tissue removed for staining. The same may be said of the so- 
called giant cells. 

The mucosa as a whole looks anaemic, and this anaemia may be due 
either to the endarteritis or, according to Wyatt Wingrave, to a toxic 
vaso-constriction. The uvula and soft palate are studded with small 
whitish points, apparently beneath the surface, and showing through the 
mucosa. In the cases called iDrimary — that is, where one is unable to dem- 
onstrate the existence of any other tubercular lesion — the deposit is apt 
to assume the form of a fringe of small excrescences extending along the 
anterior iDillars. In other places only an irregular infiltration is found, 
with nothing about it especially distinctive, at least in its earlier stages. 

After a variable time these deposits break down and form a charac- 
teristic ulcer, with reddish, eroded edges, and possibly a localized peri- 



TUBERCULOSIS, LUPUS, AND SYPHILIS OF THE PHARYXX. 



499 



oedema. These broken-down areas, though small, may coalesce, so that 
the ulcerating surface finally assumes quite large proportions. Even after 
the process has become mani- 
fest in the pharynx, the uvula 
and palate may remain for a 
long time intact. When the 
uvula eventually becomes in- 
volved, it is swollen, oedema- 
tous, and exquisitely painful. 

In spite of the painful 
character of the ulceration, 
the latter is suj^erficial, rarely 
deep. Cases of perforation 
of the soft palate have been 
reported by Grossard,^ who 
has seen two instances of this 
rare accident, and who also 
refers to a previous case of 
Talamon's and to one of Bar- 
bier's.^ In a patient seen by 
Du Cast el, ^ the hard palate 
was perforated by the tuber- 
cular process. Deformities of 
the faucial pillars may result 
from deep ulcerations. 

Symptoms. — In addition to 
the general features of tuber- 
culosis, which will vary in 
every case according to the 
extent and severity of the 
lesion, the most marked symp- 
tom is early and constant i^ain 
in the affected area. The 
uvula becomes swollen and 
oedematous : the palatal mus- 
cles become stiffened, so that 

swallowing is difficult 5 food accumulates in the recesses of the pharynx, 
and may pass to the nasopharynx ; cough is present, and it is difficult 
for the patient to keep the mouth clear of secretion. Unless the tongue 
or larynx is involved, there is not much change in the voice, though a 
peculiar hesitancy of speech is often present. Worst of all is the painful 




Pharyngeal tuberculosi?. (Chappell.) .4. primary ;£, sec- 
ondary. 



1 Ann. des Mai. de 1' Oreille, June, 1899, p. 771. 

2 Bull, de la Soc. Hop. de Paris, January 26. 1899. 



3 Ibid., October 27, 1898. 



600 



DISEASES OF THE PHARYNX. 



Fig. 186. 



swallowing. Owing to the intense odynphagia, the patient is apt to 
defer taking food as long as possible, and the emaciation due to the con- 
stitutional malady is thereby accentuated. If the lesion is confined to 
the tonsils, the pain is much less. Later there may be enlargement of 

the cervical glands. 

Diagnosis. — The characteristic appear- 
ance of the parts has already been de- 
tailed. Eeliance is to be placed on the 
coexistence of tubercular lesions in other 
l^arts of the body. An element of un- 
certainty may exist if syphilis is syn- 
chronous with the tubercle, and a differ- 




Tuberculosis of the uvula. 
Browne.) 



(Lennox 



ential diagnosis from mere inspection is 
often impossible. The diagnostician must 
depend upon the results of antisj'philitic 
medication and of general bodily exami- 
nation, and the findings from the submis- 
sion to the microscope of scrapings from 
the ulcerated surfaces or of bits of infil- 
trated tissue. Bosworth considers the 
characteristics of the typical tubercular ulcer to be a surface flush with 
the surrounding mucosa, a color the same as that of the mucosa, and a 
covering of ropy mucus. Granulation tissue is apt to have a pale color. 
Constitutional infection may cause a rise of temperature, but in the ab- 
sence of other deposits but little reliance can be placed on systemic 
symptoms. Levy finds that in the cases complicated with syphilis the 
ulceration assumes a sluggish course, has a dirty secretion, and causes 
but slight pain. In the typical sj^philitic ulcer one expects to find an 
excavated condition, with a zone of inflammation about it, and a surface 
covered with a distinctly purulent exudate. Granulations are more abun- 
dant, and there is no fever. Of course, a most careful inquiry must be 
made into the patient's previous history. 

Only about a dozen cases in children have been reported, and Comba ^ 
finds that in this class of patients there is a greater tendency to nodular 
formation with early breaking down into cheesy debris. Bleeding is fre- 
quent in children, but rare in adults. 

Frognosis. — As a rule, the prognosis is bad, but a few recoveries have 
been reported. The local condition is but one feature of the com^Dosite 
of the disease, though for the time it may be the most painful one. If 
the process is confined to a small area, energetic treatment should at once 
be begun, for if healing can be brought about, the patient's condition 
will be much more comfortable, even though he ultimately dies from the 
general tubercular affection. 



1 Lo Sperimentale, 1900, vol. liv. Xo. 3. 



TUBERCULOSIS, LUPUS, AND SYPHILIS OF THE PHARYNX. 501 

Treatment. — In adclitiou to tonic and hygienic treatment of tubercu- 
losis, a vigorous effort should be made to keep the patient as comfortable 
as possible, even though he steadily deteriorates. Climatic changes do 
not seem to be of much avail in palatal and pharyngeal tuberculosis. 
All causes of buccal irritation should be removed, the teeth placed in 
j)erfect order, and the food soft and pultaceous in consistency, though an 
effort should be made to have as great a variety as possible. The patient 
sometimes finds it easier to gulp food down than to che^v^ and swallow 
it in the usual way, or he can lie on the stomach and draw liquids up 
through a tube. As soon as the existence of tubercular tissue is ascer- 
tained, an effort should be made at eradication. Curetting under cocaine, 
with the subsequent rubbing in of lactic acid, forms the plan most in 
vogue at the i)resent time. The ulcerated surfaces should be regularly 
cleansed with hydrogen dioxide, then with a weak alkaline solution, and 
finally dusted with iodoform, europhen, aristol, or some similar powder. 
Menthol in olive oil (twenty per cent.) has had enthusiastic advocates, 
but is not used as often as formerly. Api)lications of morx^hine with tan- 
nic acid, or even cocaine, may be made for the pain, but the habitual 
use of the latter should be deferred as long as possible. Orthoform is here 
of value, and may be applied according to the formula of Freudenthal : 

Grammes. 

R Menthol 10,0 

Olei amygdal. express 30,0 

Yitelliovi 300 

Orthoform 125 

Aquae destil. q. s. ad 100,0 

This mode of preparation insures its contact as long as possible with 
the affected areas. If it is applied in i)owder it may be mixed with equal 
parts of zinc stearate or bismuth subcarbonate. It is distinctly anal- 
gesic, and seems devoid of toxic properties. A few cases are on record 
in which, after its too extensive api)lication to superficial wounds, there 
ensued headache, with fever, nausea, and dusky erythematous patches 
over various areas. For the cough, heroin in doses of from one-sixteenth 
to one-twelfth grain may be given every two or three hours. Some au- 
thorities prefer to operate with the galvano-cautery. The use of potas- 
sium iodide may reveal the true nature of a doubtful case. 

LUPUS OF THE PHARYNX. 

At the present time lupus is regarded as an attenuated form of tuber- 
culosis. It is fully recognized that while in the majority of cases of 
pharyngeal lupus the disease begins in the skin, it is possible for it to 
primarily attack the tissues of the throat. One may go further, and say 
that many cases of facial Iuidus really begin in the nasal mucosa, but are 
not recognized, owing to the painless character of the malady, until the 



502 



DISEASES OF THE PHARYNX, 



affection is far advanced. It is difficult to assign a definite cause for 
tliose cases in which the pathological process first appears in the fauces. 
Concerning the causes of lupus in general, Harries and Campbell, as 
quoted by Browne, give three factors : first, a suitable soil of undeter- 
mined nature, possibly allied to scrofula or tubercle, yet not identical 
with either ; second, a predisposing cause, perhaps a remote trauma ; 
and, third, an exciting cause, possibly a micro-organism. Browne adds 
that all of his own cases have, with one exception, been in persons of a 
distinctly lymphatic temperament. It is well known that women are 
more often affected than men. This, however, is contrary to the experi- 
ence of De la Sota.^ Some of the latter' s patients were scrofulous, others 
syphilitic, still others herpetic, and in one the only diathetic influence 
manifest was the rheumatic. The favorite age is between twenty and 
thirty years. 

The exact relation of lupus to tuberculosis is still a matter of dis- 
cussion. As stated, the profession is at present working on the basis of 
Marty's appellation of an ' ' attenuated tuberculosis." On the supposition 
that the germs of the two are identical, it has been suggested that lupus 
patients are clinically those who i)ossess sufficient vitality to offer a fairlj^ 
successful resistance to this particular form of bacterial attack. The his- 
tological differences between the two lesions are slight. The disease 
attacks by preference the soft i^alate and uvula, commonly starting near 

the free border of the former, and may ex- 
tend to muscles, tendons, and cartilages, but 
not, according to Hutchinson, to bones. The 
first evidence of invasion is an infiltration 
and hyperi)lasia of the part, which thus loses 
its normal contour. The edge of the palate 
becomes uneven and the uvula presents a 
bulbous apx)earance. The infiltration gen- 
erally shows itself in the form of nodules, 
which are discrete at first, but which finally 
coalesce, so that the resulting masses make 
the surface of the affected area very un- 
even. De la Sota calls attention to the 
early presence in the masses of a j^eculiar 
elastic resistance. They are harder than or- 
dinary inflammatory deposits, though not as 
hard as epitheliomatous formations. Hyde states that ^ ' in consequence of 
warmth and moisture the luj^oid nodule is here transformed into a moist 
papillary outgrowth or externally granulating patch." Later there en- 
sues a peculiar ulceration, or rather a wasting away of tissue, not attended 
by any purulent discharge or necrosis, but by a disappearance of the 



Tig. 187. 







Lupus of the soft palate. (McBride.) 



^ Trans. Amer, Laryngol. Assoc, 1886, p. 14. 



PLATE X. 




Lupus vulgaris of the palate and fauces. Cicatrices, dissemiuated lupus nodules, 
and large and small tubercled ridges upon the fauces, the velum, and the hard palate' 
(Chiari and Riehl.) 




Lupus vulgaris of the larynx. Tubercles and ulcerations at the base of the tongue 
and upon the swollen, crumpled epiglottis ; the left ventricular band thickened and 
tubercled. (Chiari and Riehl.) 



TUBERCULOSIS, LUPUS, AND SYPHILIS OF THE PHARYNX. 503 

previous masses. Healing then results, but not uniformly, forming a 
hard cicatrix containing strong connective-tissue bauds wliicli still fur- 
ther distort the normal contour of the parts. In this tissue fresh granu- 
lations are occasionally noted. A given case, therefore, shows healed 
areas in some places and a continuation of the active i:)rocess in others. 

Si/mjitoms. — As long as the disease is confined to the soft palate and 
uvula there are hardly any subjective symptoms until ulceration sets in. 
Some i)atients complain of a stiffness in the parts. On the advent of 
ulceration both clearness of phonation and ease in swallowing are inter- 
fered with. Subsequent cicatrization may remove both of these symp- 
toms, though if the latter leads to much distortion of the parts, these 
difficulties may remain, causing much discomfort in the swallowing of 
food, which nmy pass u^) into the nasophar^'ux. Homolle has seen one 
case with marked enlargement of the cervical glands. The process is one 
of comparative painlessness and long duration. 

Diagnosis. — The above-mentioned conditions alone will suffice to dif- 
ferentiate the affection from other forms of throat ulceration. It must be 
remembered that there are forms of faucial syphilis which in ai)i)earance 
closely resemble lupus. In a doubtful case it is a good rule to adminis- 
ter mercury and the iodides for therapeutic diagnosis, and the prac- 
titioner is especially helloed by so doing, for there is a unanimity of 
opinion among writers that in true lupus these remedies are not only 
without benefit, but that they distinctly aggravate the disease. 

Fvognosis. — The affection is of itself rarely fatal ; there is, however, 
alwaj'S danger of extension to the larynx. In some cases the throat con- 
dition has aj)peared to be the source of a general or intestinal tubercular 
infection. Patients may live a long time, subject to great discomfort, 
because of the physical condition set up by the progressive phases of the 
disease. 

Treatment. — General treatment consists of the same tonic regimen that 
is followed in tuberculosis. Iron in its various forms, cod-liver oil, hyi^o- 
phosphites, and similar remedies should be given freely. Some i^atients 
derive greater benefit from syrup of hydriodic acid. E. Law has reported 
great improvement in one i^aticnt from the use of this remed^y,^ but as 
gray powder was emj)loyed in conjunction with it, the i^ossibility of a 
specific rather than a lupoid nature of the case is suggested. One must 
bear in mind the diathetic groundwork of each case, and treat accord- 
ingly. Local measures concern the removal of the lupoid tissue. The 
uvula may be amputated, preferably with the galvano-cautery ; other 
sites of deposit should be thoroughly curetted and then cauterized. For 
this x)urj)Ose lactic acid (from five to ten per cent.) is the favorite remedy, 
as it does not attack normal tissue, a fact which commends it in prefer- 
ence to some of the other common escharotics. The galvano-cautery 

1 Jour. LaryngoL, 1896, vol. x. p. 34. 



504 DISEASES OF THE PHARYNX. 

should be employed for this purpose with great caution. Kyle commends 
the use of a gargle of hydrochloric acid, twenty minims to the ounce ; De 
la Sota a one per cent, solution of resorcin. Hollander has recommended 
hot air^ which causes, he states, a slow and progressive mortification of 
the lupoid infiltration. It is applied at a temperature of about 300° 
C, by means of a bellows attached to a metal tube, and experience has 
shown that a very good scar is obtained, but details as to duration of appli- 
cation, pain, etc., are not given. ^ Spontaneous periods of improvement 
may occur, regardless of any or all treatment. Injections of tuberculin 
and potassium cantharidate seem to be without benefit. Cazin ^ has re- 
ported a case with infiltration of the velum and faucial ]3illars which 
was cured by an intercurrent attack of erysipelas. Mention may also be 
made of the benefit received by some patients from exposure to the 
X-rays or to the ultra-violet rays of white light, the latter method having 
been elaborated by Finsen, of Copenhagen. With both of the latter plans 
of treatment some quite brilliant results have been obtained in cutaneous 
lupus, and, while their application to pharyngeal disease is vastly more 
difficult, they may be so perfected as to become directly available for 
this condition. 

SYPHILIS OF THE PHARYNX. 

Next to the skin, the mucosa of the fauces and pharynx is doubtless 
most frequently affected by the syphilitic virus. It is rare to find specific 
lesions confined to this site, but they can be here examined with especial 
facility. 

Other works must be consulted for the results of the most recent ob- 
servations as to the nature of the specific poison. There is every reason 
to believe that it is a living organism, though it has not as yet been iso- 
lated. It is assumed that the virus has no power to penetrate intact skin 
or epithelia, and that inoculation imi)lies either a breach in the super- 
ficial tissues or the introduction of the poison beneath them, though it 
maj^ enter either a follicle or beside the hair-roots.^ The jDcriod of in- 
cubation varies from one to eight weeks ; then comes the local lesion, 
followed by the systemic changes. Unless the latter are influenced by 
treatment, they may continue for an indefinite time, characterized by 
latent or quiescent jDeriods. In certain instances it may be imi^ossible 
to detect the initial changes ; this may happen in cases of infection 
from syphilitic semen or by retro- infection (during pregnancy) from the 
foetus. The manifestations of the disease in the pharynx and fauces may 
now be considered, it being x^remised that previous acute and chronic 
inflammations predispose to infection. 



1 Presse Med., October 30, 1897, p. 269. 

2 Ann. des Mai. de F Oreille, 1880, p. 33. 

' Lang, Twentieth Century Med., vol. xviii. 



TUBERCULOSIS, LUPUS, AND SYPHILIS OF TPIE PHARYNX. 505 

The Initial Lesion. — This occurs most frequently ou the tonsils, but 
may show itself on the anterior and even the i^osterior surface of the soft 
palate. Examination shows a chancre more or less distinctly marked, 
which later may become eroded or ulcerated from the irritation which its 
exi^osed site occasions, and which is constantly followed by a painless en- 
largement of the adjoining lymj)h- nodes and in due time by constitu- 
tional symptoms. 

Erythema. — This is one of the ••secondary"' features of syphilis, and 
appears at any time from the sixth to the sixteenth week after the initial 
lesion. The mucosa assumes a somewhat purj)lish color, which has been 
referred to passive congestion. In the milder cases this lesion is limited 
to the lips and cheeks, but it may extend over the tonsils, uvula, soft 
palate, and posterior j)haryngeal wall. The areas involved vary in size 
from a pea to a penny. The erythema is generally a symmetrical one, 
reaching from the centre to both sides, and shows sharp demarcation 
from surrounding tissues, especially at the junction of the hard and soft 
palates. The median line sometimes escapes. In fact, such a demarcation 
and situation of the erythema at once suggest specific disease, though 
these features alone do not make the diagnosis positive. The skin may 
present erythematous or pai^ular lesions, which will, of course, assist in 
the diagnosis. The foregoing api)earance of the throat is often distin- 
guished with difficulty (in the absence of other information) from an 
ordinary catarrhal condition. 

The Mucous Fatch. — While this is usually spoken of as a secondary 
lesion, and is vasth' more common in the early stage of specific disease, it 
is a possibility at any tioie. It poisons the buccal fluids, and so represents 
from its potential danger the most infectious stage of syphilis. The 
patches are ovoid, shallow, and may be symmetricallj' located. They 
rei3 resent areas in which there is an exudation of serum with a free 
supply of imi:)erfectly develoi)ed cells. These changes cause the very pale 
color characteristic of the patch. If this condition progresses without 
treatment, the area itself and a certain zone around it break down, thus 
forming a superficial ulcer, which dries up, leaving a small stellate cica- 
trix. Bosworth maintains that the nature of this process is the same 
as the breaking down of a gummatous deposit (see below), the only dif- 
ference being that the former is milder and earlier while the latter comes 
later and is more severe. In either case the essential change in each is 
one of infiltration of the tissues and of the vessel-walls with embryonic 
cellular contents, atrophy of the surface, and gradual breaking down. 
There is no such thing as erosion from the specific virus. 

The Gummy Tumor. — This is the distinctive manifestation of the ter- 
tiary stage, occurring from five to fifteen 3 ears after the initial lesion. A 
favorite site is on the posterior surface of the soft palate, where the gumma 
may for a long time be unperceived. Gummata rarely pass over ana- 
tomical boundaries, — that is, do not extend directly in front of the faucial 



506 



DISEASES OF THE PHARYNX. 



pillars, above tlie pharyngeal tonsil, or into the larynx. They api^ear 
either as nodules or as a diffuse infiltration, and may form rapidly and 
undergo rapid destruction, the cell-crowding shutting off the blood-supply. 
These cells are small, round, and embedded in a soft gelatinous basement 
substance. In the nodular form a bulging mass is found, the mucosa over 
which is distinctly reddened. 

Later these deposits undergo cheesy degeneration, becoming sur- 
rounded by a zone of granulation-tissue, which sometimes becomes fibrous. 
Actual abscess formation is not unknown, though this phase of degenera- 
tion is more apt to occur in internal organs than at the site under con- 
sideration. Destruction does not pass beyond the confines of the original 
gummy deposit. Large areas may be destroyed, while strings or bands 
of fibrous tissue reach from one part to another, completely distorting the 
pharynx. As a result of new physical relations of the parts involved. 

Fig. 188. 





Adhesion of uvula to faucial pillars ; ulcer in left tonsil. (Lennox Browne.) A. state of repose 

B, contraction on inspiration. 



regurgitation of fluids into the nose in the act of swallowing is apt to 
occur ; also the soft palate may become adherent to the posterior pharyn- 
geal wall. As a rule, this adhesion is not complete, there being left a 
small aperture which may be hard to locate ; but cases of complete adhe- 
sion have been reported. The destructive process sometimes affects the 
hard palate, so that it is possible to look directly from the pharynx u^) 
into the antral cavities adjoining the nose. Erosion of large vessels occa- 
sionally occurs. 

Gummatous infiltrations are more rarely absorbed in the pharynx than 
elsewhere, and most of them go on to ulceration. Lang states that, as a 
rule, the process in both buccal and pharyngeal cavities is exceedingly 
sluggish as regards individual foci of infection, and also with respect to 
the formation of new nodules during the presence or after the healing of 
old ones. He likewise calls attention to the fact that gummata may here 



TUBERCULOSIS, LUPUS, AXD SYPHILIS OF THE PHARYXX. 507 

rarely run an acute course, so that within a few days a frightful destruc- 
tion of tissue takes place, such as would not ordinarily have occurred 
until after the la^^se of months or years. 

Si/mjyfoms. — The initial lesion is more frequent in men, especially those 
with enlarged or previously inflamed tonsils. The antecedent condition 
favors infection by presenting a territory of impaired epithelial integ- 
rit}^ The patient comj^lains as of an ordinary sore throat, the pain 
being greatly increased by attempts at swallowing. Cervical adenopathy 
comes on early, and local suppuration in the glands has been observed. 
Constitutional symptoms are rareh' present at this time, and diagnosis from 
a malignant growth is sometimes required. Early eruption, saj' in from 
two to four weeks, will resolve all doubt, and it is a common experience 
that many ulcerations of an indefi- 
nite nature, so far as their appear- ^^^^- l^^- 
ance is concerned, clear up under ^hy, 
the use of the iodides. ''"' '"' 

In erythema there are a peculiar 
stiffness of the throat and pain on 
swallowing. Localization of the 

erythema in the soft palate and , . . . ., .. , . . ^^ 

faucial pillars or its sharj) demar- ^ ^'— - - ]f' 

cation generally enables the i^racti- 
tioner to make a diagnosis without 
difficulty. 

In the mucous patch there is usu- 
ally extreme sensitiveness, which is 
increased by irritating ingesta, by tobacco, and by the use of the voice, and 
may become so acute as seriously to interfere with the patient's nutrition. 
Diagnosis is made from the fact that the patches generally apjDcar in 
groui)S, occurring in order of frequency (Bosworth) on the soft i^alate 
and uvula, anterior sui^face of the anterior pillars, tonsillar convexities, 
-and anterior surface of the jDosterior pillars. The author just quoted 
also notes that a collection of i)atches on one side may reproduce itself 
on the other in an absolutely symmetrical way, and the reason assigned for 
this is the contact of the parts in swallowing, during which the two sides 
are brought into complete apposition. Older patches may be cracked 
or fissured, with a zone of inflammation which is wanting in the earlier 
stages. A fresh patch looks as if the mucosa had been lightly brushed 
with a strong solution of silver nitrate. A few cases are on record in 
which the patch has assumed the gross form of a fibrinous exudate and 
has been mistaken for diphtheria, having been attended bj^ marked 
constitutional symptoms. 

The gumma gives symptoms which are mainly mechanical, affecting 
swallowing and speech. When ulceration has begun, pain may become 
severe. Contrary to the secondary manifestations, the disease begins as 




A.ctive tertiary ulceration of the pharynx, with 
old scar formation. (Lennox Browne.) 



508 DISEASES OF THE PHAEYNX. 

a unilateral one, usually first showing itself in one of the tonsils and the 
adjoining pillars or on one side of the posterior pharyngeal wall. The 
typical tertiary ulcer is deeply excavated, with sharply defined edges, 
surrounded by a red, angry-looking area, and pouring out an abundant 
bright yellow purulent discharge. 

Diagnosis. — While advanced conditions are not likely to offer any 
special difficulty in diagnosis, it may not be so easy to determine the 
existence of syphilis when the case is seen before the ax)pearance of any 
but faucial lesions. Many of them i^resent only catarrhal symptoms, 
with, at times, a little general disturbance. The physician should search 
for enlarged glands, and may find in the mouth thick, tenacious secretion, 
causing difficulty in speaking and swallowing. The important point is 
to regard with suspicion all cases which do not yield to sim^^le anti- 
catarrhal remedies, although there may be no history of specific disease 
and no other evidence thereof than the obstinate throat discomfort. The 
sequel most to be feared is the deformity of the pharynx, which may 
assume all sorts of shapes, and which has already been mentioned. 

In regard to the diagnosis of the disease in its earlier phases, mention 
may be made of the so-called ''Justus Blood-Test," concerning which an 
interesting article has been written by D. H. Jones. ^ The test is based 
on the alleged fact that a single inunction of mercury in all untreated 
cases of congenital, secondary, or tertiary syphilis causes a reduction in 
the haemoglobin, due to the sensitiveness of the red blood-cells to the 
action of the drug, while in non-syphilitics no reaction follows. Jones 
reports an experience with fifty-three cases, but concludes that the test is 
by no means an infallible one. 

Treatment. — This should in all cases be prompt and energetic. Mer- 
cury and the iodides must be given in such sequence and combination as 
the individual case demands. Alcohol and tobacco must be absolutely 
forbidden, and care taken that the food be bland and unirritating. Hy- 
giene of the mouth must be enforced by the use of a soft tooth-brush and 
rinsing after meals with some antiseptic solution of weak strength. If 
deglutition be extremely painful, a weak solution of cocaine may be used 
at first, care being taken not to exceed a safe internal dose. Local lesions 
should be thoroughly cleansed with an alkaline spray (Dobell's) or with 
hydrogen dioxide diluted with one-third lime-water. The parts may 
then be dusted with iodoform or, better, orthoform ; if possible, this 
should be done each day. For home use as a cleansing wash, and for a 
direct effect upon the lesion, the familiar ''black wash" diluted with an 
equal bulk of water may be used for the early, and bichloride of mer- 
cury (1 to 3000) for the late, lesions. Each mucous patch should be 
touched with silver nitrate. Indurations of the mucosa may be painted 
with a solution of bichloride of mercury (gr. ii) in sulphuric ether (3 v), 

1 New York Med. Jour., April 7, 1900, p. 513. 



TUBERCULOSIS, LUPUS, AXD SYPHILIS OF THE PHARYXX. 509 

while a ten per cent, solution of iodoform in ether may be sprayed on 
fissured ulcers. If palatal perforations have resulted, it is sometimes 
possible, if they are small and recent, to heal them under the combined 
effect of constitutional treatment and application to their edges, on alter- 
nate days, of mono- or trichloracetic acid. 

For the relief of after-deformities many plans of treatment have been 
devised, but no general rule can be laid down. Some patients show tis- 
sue damage which is irremediable, and the features of each case must be 
studied by themselves. The main i)roblem after separation of adhesions 
is to prevent their recurrence. For the separation of the soft palate from 
the posterior pharyngeal wall there is probably no better operation than 
the one devised by the late J. E. H. Xichols.^ 3Iost if not all other 
operations have the fotal defect that the cicatricial tissue advances in the 
process of healing from the bottom of the incision ; hence the original 
method of formation of the adhesion is reproduced. Healing begins 
from the apex of an incision and progresses towards its edge. The de- 
nuded surface does not heal at once through its whole extent, for in that 
case a simi)le incision would sufi&ce to cure the most pronounced case. 
Xichols's operation is the ax^plication of the principle involved in treating 
a webbed-finger case. Under cocaine anaesthesia, curved right-angled 
staphylorrhax^hy needles, one for each side, and on long handles, are 
threaded with silk (Xo. 13), i^assed through the median opening into the 
nasopharynx, and then brought out into the mouth again on each side as 
far as the shape of the needle will i)ermit, back close to the pharyngeal 
wall. To the thread is attached one of larger size (Xo. 16), which is drawn 
through the same track in the reversed direction. Knots are tied in each 
of the loops, which are teased along until they lie in the nasopharynx. 
These loops are left in position for a week or two, attachment being pre- 
vented by the movements of the pharynx. At the end of this time the 
little canal in which the looi:)S lie will have become firm and cicatrized 
tissue. The loops are then cut and withdrawn, leaving the canal free. 
A long knife, with its cutting edge at right angles to the handle, is then 
pushed through the cicatricial canal with its edge towards the median 
line, and the tissue between it and the central opening is cut through, 
care being taken not to injure the tissue at the back of the knife, — i.e.^ 
the canal made by the needle. In a few days healing of the cut edges 
will have taken place, but they will remain separated because of the 
band of cicatricial tissue at the apex of the cut. Thus the nasopharynx 
will be opened by just so much as the depth of the incision. It may be 
necessary to repeat the operation several times until adequate space has 
been obtained. Various sounds, curved to fit the nasopharynx, have been 
devised from time to time, but the operation above described is the best 
for all cases approaching complete occlusion. 

^ Trans. Amer. Laryngol. Assoc, 1896, p. 161. 



510 DISEASES OF THE PHARYNX. 

Congenital Syphilis of the Pharynx. — Our knowledge of this 
condition is largely dependent on a careful study by J. ^. Mackenzie.' 
Among his conclusions the following are pertinent to the special matter 
under consideration. 

(1) Deep ulceration may invade the j)harynx at any period of life 
from the first week up to the age of puberty. (2) When the eruption of 
inherited syphilis is apparently delayed until the latter period, the le- 
sions of the palate and pharynx are found with a peculiar constancy, and 
often first attract attention to the existence of a diathesis of which they 
are the sole pathological expression. (3) Females are more often attacked 
than males. (4) Ulceration may occur at any site, but the palate is the 
favorite one. (5) When situated at the posterior portion of the hard pal- 
ate, the tendency of the ulceration is to 
Fig. 190. involve the soft palate and velum and 

^^^^^^?'i^ ,,, thence to invade the nasopharynx, while 

^r ^r ^ " *^ ' C' when situated more anteriorly, ulceration 

'^^jT ^i i ^\,^^ reaches the nose directly by perforation 

^*%^; of the bone. (6) The next most frequent 
^tM(\ ^\ sites of ulceration are the fauces, naso- 

'? ^tf^'j ^^ --^ pharynx, posterior pharyngeal wall, nasal 

fossa and septum, tongue, and gums. (7) 
Ulceration (especially that of the palate) 
shows a disposition to centrality with a 
special tendency to caries and necrosis. 
This tendency to necrosis exists at all pe- 

Ulceration of velum m congenital syphi- . , ^ -, . ^ , • -.i . i t 

lis. (Lennox Browne.) riods of liie, but especially in early youth, 

at which time it is more destructive and 
less amenable to treatment. The congenital forms of ulceration show little 
tendency to invade the larynx (Fig. 190). 

Another point of interest mentioned by the same authority ^ is the fact 
that these local ulcerations, due to inherited syphilis, are often influenced 
by any intercurrent febrile affection, notably by measles and scarlet fever 
(not diphtheria). The supervention of scarlet fever may cause a complete 
disappearance of the ulcers. The poisons of the two conditions in their 
circulation in the regions named appear to be mutually destructive, and 
the throat escapes by virtue of such reciprocal antagonism. Cure may 
be permanent or relapse may follow the subsidence of the intercurrent 
affection. 

1 Am. Jour. Med. Sci., October, 1880. 

" Trans. Amer. Laryngol. Assoc, 1884, p. 16. 



CHAPTEE TIL 

ERYSIPELAS, HERPES, PEMPHIGUS, AXD DIABETIC ELCERATIOXS OF 

THE PHARYNX. 

Erysipelas of the Pharyxx. — Erysipelas may occur in the pharynx 
as a primary or a secondary lesion ; if the latter, it is an extension of 
the cutaneous manifestations so common about the head. Cases have 
been reported in which infection has seemed to come from some distant 
part of the body. As a x^rimarj- disease it is comparatively rare, though 
perhax^s some of the milder attacks have not clinically differentiated 
themselves from other forms of angina, their real nature being over- 
looked. 

Etiolof/ij. — '"Erysipelas is caused in man,'' says Kiliani,^ '^•by the ac- 
tion of a chain coccus identical with the strex)tococcus pyogenes, that 
causes suppuration in various parts of the body, from a simple abscess of 
the skin to a fatal peritonitis, and which may be the cause of septicaemia 
without supx)uration.*' The i:)articular micro-organism of the disease is 
known as the streptococcus erysipelatis of Fehleisen, its discovery dating 
back to 1882. The most freciuent mode of transportation of the virus is 
by contact, such as from handling either a patient ill from the disease or 
the bedding and other surroundings which through him have become 
contaminated. 

Fatliology. — Three grades of severity of the affection may be distin- 
guished : (1) simple redness of the i3arts ; (2) formation of phlyctcenul^e ; 
(3) a continuation of inflammation leading to gangrene. The tissues are 
swollen and brawny, though there may not be the sharp demarcation of 
the limit of infiltration one is accustomed to see when the disease is con- 
fined to the skin. 

Symptoms. — The disease begins with a chill, followed by high fever and 
its usual accompaniments, together with intense i)ain and difficulty in 
swallowing. The swelling of the x^haryngeal mucosa is pronounced from 
the start, though the characteristic ef&oresceuce may be somewhat de- 
layed. The starting-i^oint is generally the lymi:>hoid tissue at the base of 
the tongue, but extension to the exoiglottis and aryepiglottic folds may 
occur, quickly causing marked dyspnoea. This early extension explains 
the suddenness with which oedema may threaten life. 

Diagnosis. — Xotwithstandlng the difficulty of an early diagnosis, the 
promi^t recognition of the malady is a matter of the greatest imi^ortance. 
If oedema of the glottis results, the prognosis is generally fatal, in spite 
of either intubation or tracheotomy. It may be that the serous inflltra- 

1 Twentieth Century Med., vol. xvi. p. 409. 

511 



512 



disp:ases of the pharyxx. 



tion of the mucosa and submucous tissues becomes purulent, leading to 
sepsis, or the larynx may become the seat of supi^urative processes, or 
there may be the usual carbonsemia from laryngeal stenosis. A well- 
defined margin of infiltration in association with constitutional symptoms 
would suggest erysipelas, even in the absence of the cutaneous lesions. 

Prognosis. — This is always grave, though recoveries have been reported. 
Delavan ^ has reported the case of a man twenty-nine years of age in 
whom the disease first appeared on the tonsils, and who later developed 
cerebral symptoms eventually ending in insanity. The same author 
quotes statistics of Cornil showing that out of nine instances in whicli 
the disease first appeared on the face, and later in the pharynx, seven 
died, while in nine others in which the pharyngeal exanthema appeared 
first and was followed by the external invasion, seven recovered. 

Treatment — No better constitutional remedy has ever been found than 
the muriated tincture of iron, of which thirty minims should be given 
every three hours ; it should be well diluted with glycerin ahd water. 
Externally, ice compresses or the Leiter cold-water coil may be applied. 
Later, resolvents, such as large mustard-plasters, should replace the cold 
applications. On the inflamed tissues may at first be painted solutions 
of cocaine or menthol to relieve i)ain, and later, with a view of controlling 
the specific process, fifty per cent, ichthyol in glycerin. The rapid prog- 
ress of the disease in the pharynx, and the fact that the first inspection 
will iDrobably show the process well advanced, make all applications to 
limit it of doubtful efficacy. Alcohol and strychnine will be needed to 
combat depression. Pilocarpine has been suggested as having a bene- 
ficial effect on pharyngeal erysipelas, but should be used, if at all, with 
great caution, owing to its effect on the heart. The antistreptococcus 
serum has benefited some cases, but entirely failed in many others. Local 
antisepsis should be enforced. (Edema of the larynx or adjacent parts 
calls for scarification. In cases of threatening asphyxia the surgeon may 
intubate or perform tracheotomy, but, as has been said, these cases are 
fatal, the patients dying of sepsis. Marmorek asserts that he has devel- 
oped an immunizing serum for the affection. 

Herpes of the Pharynx. — This affection consists in the occurrence 
on the inside of the cheeks, uvula, soft palate, and occasionally on the 
tongue of small blister-like patches resembling those of cutaneous herpes. 
Earely the tonsils and epiglottis are invaded, but the posterior pharyngeal 
wall generally escapes. The lesion may be unilateral or bilateral, and 
may occur simultaneously on the genitals, about the nose, and on the lips. 

Miology. — Among the causative factors are exposure to cold or to 
septic influences, especially bad drainage, menstrual irregularities, and 
febrile states. It is more common in delicate children and neurotic 
girls, and is especially prevalent in cold and damj) climates and during 

^ Trans. Amer. Laryngol. Assoc, 1885, p. 48. 



HERPES OF THE PHARYXX. 513 

diplitheria epidemics. Many of the patients are distinctly anemic : 
others present gouty or rheumatic tendencies. Some authors place the 
disease under the heading of j)haryngeal neuroses. 

Fathology. — The initial stage is characterized by vesicles singly or in 
patches and distended with serum. This stage is rarely seen, however, 
for the raised epithelial covering is so fragile that it quickly bursts, 
leaving either no trace or, at best, a shallow ulcer. Sometimes the 
patches coalesce, forming a large bulla, which, after evacuation, becomes 
covered with a membranous deposit. This, however, is easily removed, 
and may i^artially detach itself, remaining in the throat like a loose cur- 
tain. Bosworth records three cases resembling herpes iris : "small rings 
of minute papules enclosing a patch of healthy mucous membrane. * ' The 
process has been regarded as a neuropathic one, some considering it as a 
herpes zoster of the trifacial nerve. Herzog has suggested as the funda- 
mental cause irritable conditions in the region of the nerve-branch sup- 
plying the pharynx and the posterior nasal nerve as well as the Vidian. 
The theory most commonly accepted is that of a localized inflammation 
of the papillcie of the subepithelial layer of the mucosa originating in the 
terminal nerve filaments. Bacteriological investigations have thus far 
been negative. 

Symptoms. — These may be ushered in by severe gastric disturbances, 
lasting two or three days, or by a x)ronouuced headache. A moderate 
febrile reaction develops, followed by itching or burning in the fauces, 
increased by swallowing, and attended by profuse salivation. The local 
discomfort may radiate to the nose, ears, and sometimes to the larynx. 
Inspection shows the lesion as above described appearing in several 
croi)S, lasting two or three days. ^Mien first seen it may be papular or 
vesicular ; later the vesicle contents may become purulent. The sub- 
maxillary glands are often enlarged : deep ulceration has been noted, and, 
according to Herzog. even palatal perforation. Following the subsidence 
of the acute stage the soft i)alate may be parah'zed, a fact strengthening 
the neuropathic theory of the disease. Successive crops of eruption may 
prolong the course of the disease to somewhat over a week. After recov- 
ery the pharyngeal mucosa seems to be unusually sensitive to all infec- 
tious agents. 

Treatment. — Special attention should be paid to the general integrity 
of the nervous system, as relapses are very common. In distinctly neu- 
ropathic subjects excellent results have been obtained with arsenic, which 
may advantageously be combined with iron and strychnine (arsenous acid, 
one-twentieth of a grain ; strychnine sulphate, one-thirtieth of a grain ; 
powdered iron, two grains ; after meals). Cases showing rheumatic ten- 
dencies need the salicylates. Tincture of aconite is highly commended 
by Schech. Locally, sedative and demulcent mouth-washes may be used. 
Potassium chlorate should not be employed, as it seems distinctly to ag- 
gravate the condition. In case the patches show an inclination to si^read, 

33 



514 DISEASES OF THE PHARYNX. 

mild caustics may be used. Over the affected areas morphine and car- 
bolic acid or cocaine and menthol, in some bland unguent, may be applied. 

Pemphigus of the Pharynx. — The large vesicles characteristic of 
pemphigus are sometimes seen in the throat 5 they may be antecedent 
to the same lesion on the skin or may occur indei^endently. The pharyn- 
geal localization of the disease appears to be very rare in America, but 
numerous cases have been reported by Continental observers. Concern- 
ing the exact nature of the affection oj)inion is still unsettled, though it 
is generally regarded as a trophoneurosis. The disease has been ob- 
served in the syphilitic dyscrasia and in women suffering from uterine 
disorders. 

The vesicular stage may last only a few hours, being ushered in by a 
pricking sensation in the throat. The epithelial covering speedily be- 
comes thinned by maceration and bursts, and the resulting erosion may 
quickly heal or may become coated with a fibrinous layer holding in its 
meshes mononuclear and polynuclear leucocytes. The eruption does not 
spread all over the throat, but seems to restrict itself to, and reproduce 
itself upon, certain selective areas. 

Symptoms. — The acute form of the disease is ushered in by fever, 
nausea, and vomiting. Deglutition becomes difficult and even painful. 
Speech may be indistinct, and dyspnoea has been observed. In the 
chronic forms may be noted as diagnostic features ^ clear watery blebs, 
or membranous patches with regular but well-defined edges on an in- 
flamed base, or red areas free from membrane and looking as if var- 
nished 5 the intervening mucosa is normal. The conjunctivae may pre- 
sent a similar lesion. The patients are often debilitated, and the affection 
is extended over many years. Avellis ^ has seen one case of adhesion of 
the soft palate to the posterior pharyngeal wall resulting from pem- 
phigus, and alludes to three others. 

Treatment. — The sheet-anchor is arsenic given internally up to full 
physiological tolerance ; no other drug seems to have the least specific 
effect. Debilitated states and the presence of any dyscrasia suggest their 
own remedies. It may not be amiss to refer here to a case of pemphigus- 
like eruption which followed the use of antipyrin, reported by G. 
Lyon.^ In this instance both the skin and the pharyngeal mucosa were 
affected. Finally, in speaking of throat eruptions, it must be remem- 
bered that this area may present many varieties of toxic erythemata 
coming from a disordered stomach and bowels. Full purgation will cause 
all of these quickly to disappear. 

Diabetic Ulcerations of the Pharynx. — Joal, in 1882, was the 
first to call attention to the peculiar appearance of the pharynx in 

^ Menzel, cf. Laryngoscope, vol. vii. p. 63. 

2 Munch. Med. Woch., March 6, 1900. 

'^ Cf. Centralb. f. Lar., 1898, Bd. xiv. S. 85, 



DIABETIC ULCERATIONS OF THE PHARYNX. 515 

diabetes, though, in an indefinite way, in this disease dryness of the 
parts has long been recognized. The subject has also been studied by 
various authors since that time. Garel ^ distinguishes two stages of the 
condition, one of hypersemia and the other of anaemia, regarding both as 
parts of the same process. He does not consider the atrophic form as dif- 
ferent in appearance from the atrophy seen in manj^ other systemic or 
local conditions, but the hypersemic form presents characteristic clinical 
features, and is of special imi)ort from its early appearance and prognos- 
tic significance. The notable features are pharyngeal dyssesthesia, diffi- 
culty in swallowing the saliva, swelling of the pharyngeal mucosa, and 
exaggeration of the pharyngeal reflexes. The foregoing are not abso- 
lutely diagnostic of diabetes, for some of Garel' s patients showed albu- 
min but no sugar. In fact, out of twenty-one only ten had sugar, while 
eleven had albumin. The main lesson to be learned from such experi- 
ence, and one upon which Garel strongly insists, is the necessity of 
examining the urine of every patient, not alone in hospital but also in 
private practice. Many obscure cases may thus be unravelled. 

W. Freudenthal ^ has reported a series of cases j) resenting pharyngeal 
ulcerations due, he thinks, to diabetes. He has seen three instances of 
ulceration occurring in diabetes of a milder type, two of which involved 
the larynx. In one of the latter great relief and finally healing resulted 
from the use of orthoform. 



^ Ann. des Mai. de 1' Oreille, February, 1895. 
^ Laryngoscope, February, 1900, p. 92. 



CHAPTEE YIII. 



TUMORS OF THE PHARYNX. 

Under this heading are considered tumors of the fauces and tonsils 
as well as of the pharynx proper. The inflammatory affections of these 
organs will be considered later. 

A. Benign Growths. — An approximate idea of the frequency of 
new growths in this general situation may be obtained from the table 
given by Moritz Schmidt.^ Out of 32,997 patients seen in the course of 
ten years, the following number presented benign growths : papillomata, 

29 men, 11 women, total 40 ; fibro- 
^^^- ^^^- mata, 1 man, 2 women, total 3 ; ton- 

sillar polyps, 3 men, 2 women, total 
5 ; cystic tumor, 1 man ; total of 
benign growths, 49. 

The most common of all are the 
papillomata. These are generally 
found on the anterior edges of the 
soft palate and on the uvula, though 
cases of true papilloma of the ton- 
sil are not unknown. They vary 
in size from a pin -head to a small 
cherry. Their origin is not defi- 
nitely knowQ ; they may be refera- 
ble to irritation from food and from 
the attrition of opposing surfaces, 
but if these are the only causes 
it is hard to see why they are not 
vastly more common. One or two 
cases of supposed papilloma have 
seemed from their early recurrence, 
and have later been actually found, 
to be true malignant growths. They 
occur as cauliflower-like masses, examination showing them to consist 
of connective-tissue papillse, with an investment of epithelium so spread 
over the growth as either to form a smooth tumor or, especially at this 
site, a separate envelope for each papilla, through the entire length of 
which runs a single loop of blood-vessels. 

As has been stated, true x^apiHomata of the tonsil sometimes occur, 




Papilloma of the soft palate. (Bosworth.) 



1 Die Krankh. der oberen Luftwege, 1894, S. 480. 



516 



TUMOPvS OF THE PHAEYXX. 
Fig. 192. 



517 




Papilloma of the uvula. (Seifert and Kahn.) a,coveringof pavement epithelium ; ?>, b.papillse 
c, arteries ; t1, dilated veiu ; e, cellular infiltration. 

Fir,. 193. 







^S:-.- -.3!* 






d a 

Fibroma of the soft palate. (Seifert aud Kahn.) a, a, epithelial layer; b, superficial depression; 
c, fibromatous librillated connective tissue ; d, arteries -with thickened walls ; e, dilated vein. 



518 DISEASES OF THE PHARYXX. 

though some of the cases reported under this heading have not been true 
papillomata, but rather lympho- or fibro-angiomata. Both have a covering 
of stratified epithelium, but differ in their stroma. In the former the 
bulk of the growth consists of pure lymphoid tissue, while in the latter 
this tissue is interspersed with fibrous bundles. Wyatt Wingrave ^ ob- 
serves that the true papillomata generally grow from the surface of the 
organ, while the so-called polypi (sometimes mistaken for the former) 
spring from the interior of the lacunse. 

As will be noticed by referring to Schmidt's figures, fibromata are far 
less common, and his experience coincides with that of other clinicians. 
These tumors are of slow growth and hard consistency. Several varieties 
of mixed tumors, such as fibro-enchondroma, fibrolymphadenoma, etc., 
have been seen in the pharynx. 

During the last few years several cases of lipomata and fibrolipomata 
have been recorded. All of the foregoing were confined to the tonsil. 
Eipault ^ has seen a fibrolipoma of the soft palate which seemed to have 
separated the anterior and posterior surfaces of that structure. It was 
dissected out, the mucosa trimmed, and the two surfaces of the velum 
united by a row of sutures extending across the throat. A hsematoma 
followed this operation, but eventual recovery without recurrence is re- 
corded. Avellis ^ reports the case of a pedicled lipoma of the tonsil in a 
boy of twenty, containing, as most of these growths in this situation do, 
a delicate connective-tissue framework. He suggests the theory that cer- 
tain fat-cells of the embryonic state become dispersed, lodging in the 
tonsil, and that later the lessened resisting power of neighboring cells 
allows of their over-develoi)ment and the formation of a tumor. This 
seems a reasonable supposition, for no fat- cells normally enter into the 
formation of tonsillar tissue. 

Angiomata are rare. Four cases are reported by Bosworth, in one of 
which (that of W. C. PhillixDs) the large vessels extended from the uvula 
over the soft palate, causing a difficulty in swallowing sufficient seriously 
to interfere with nutrition. Another case has been seen by Magnan.* 
T. E. Chambers ^ reported the case of a boy sixteen years old who, 
probably as the result of trauma, showed a bluish tumor on the anterior 
aspect of the left posterior faucial pillar. J. Wright^ has seen one in the 
middle of the lingual tonsil. In all of these cases of angiomata forcible 
inspiration will often greatly diminish the size of the mass. 

Adenomata of the palate are not uncommon, there being quite a large 
list on record. Most of them have occurred in patients between the ages of 

^ Jour. LaryngoL, 1898, vol. xiii. p. 132. 

2 Ann. dea Mai. de 1' Oreille, 1898, vol. xxiv. i3. 457. 

' Arch, f . Lar., Bd. viii. S. 560. 

* Jour, de Med. de Bordeaux, February 22, 1896. 

^ Cf. Laryngoscope, 1900, vol. viii. p. 237. 

^ Laryngoscope, 1897, vol. ii. p. 190. 



TUMOES OF THE PHARYXX. 519 

twenty and fifty. Statistics show them to be twice as common in women 
as in men. The writer has seen one case of fibro-adenoma in a man aged 
sixty, involving the left anterior portion of the soft palate and sending a 
prolongation backward and upward behind the ascending ramus of the 
inferior maxilla, complete removal being somewhat difficult. These 
tumors are usually sessile and of slow growth, and do not, as a rule, 
form any adhesions with surrounding parts. They are often mistaken 
for fibromata, but the latter grow more rai)idly, are more aj^t to be painful, 
and cause more disturbance by their mechanical pressure. According to 
Schech, adenomata are always situated on one side of the middle line of the 
anterior surface of the soft palate, and are develoi)ed from the submucous 
glands. Their surface is slightly smooth or mammillated, and their size 
varies from that of a hazel-nut to that of a hen's egg. The glandular 
acini may become so dilated as to form small cysts in the bulk of the 
tumor. - The connective- tissue elements of the growth may be arranged 
near its surface in such a way as to form a sort of capsule, thus rendering 
enucleation easy. 

Tumors of the oroi:)harynx are rare. Bosworth reports seven cases 
of fibroma and two of dermoid growths. Avellis ^ saw a child a few hours 
after birth in whom there was a polyp of the left pharyngeal wall, causing 
imminent danger of asphyxia. The mass seemed to lie on the base of 
the tongue. The uvula was wanting, the posterior segments of the soft 
palate having failed to unite. The growth was as large as the phalanx 
of the thumb of an adult, and bj^ palpation could be traced to the general 
region of the left tonsil. It was drawn forward with forceps and removed 
with a galvano-cautery, with instant relief from the threatening symptoms. 
Examination of the tumor showed it to be a teratoma. A complete bibli- 
ography of the literature of these rare growths was given by Conitzer^ in 
1892. Mention may be made of a case of molluscum pendulum of the 
tonsil reported by Furet' as occurring in a male adult, probably the only 
case of the kind on record. 

Cysts of the tonsils have been seen by various writers, who agree in 
the general statement that the contents are thick creamy mucus and e])i- 
thelial cells. Sometimes they seem to project from the surface of the 
tonsil, while at others the mucosa shows at a certain jioint only a bluish 
discoloration, a portion of the thin cyst -wall showing a fine vascular net- 
work. 

The symptoms of all the foregoing are referable to their size, shape, 
and situation. Man 3^ of the pai)illomata are so small that their jiresence 
is never noted by the patient, and they come to light only when a sys- 
tematic examination of the throat is made by a physician. After the 

1 Eev. Int. de RhinoL, 1893, No. 10, p. 219. 

2 Deut. Med. AYoch., 1892, No. 51. 

3 Arch. Int. de LaryngoL, 1897, No. 4, p. 473. 



520 DrSEASES OF THE PHARY^sX. 

neoplasm has attained a certain size there may be indistinct speech, diffi- 
culty in swallowing, and the constant feeling as of a foreign body. If 
the growths become pedicled, they may be canght in the teeth and be 
accidentally bitten off, or they may fall backward and irritate the glottis, 
thus causing cough and even dyspnoea. Adenopathy is absent. 

The treatment of all is purely a matter of surgerj^ Some of the 
smaller ones can readily be snipped or snared off. It is a good plan to 
remove a little of the mucous and submucous tissue surrounding the 
base of the growth in order to prevent recurrence. Sessile growths re- 
quire some form of ecraseur. For angiomata the ideal method of removal 
is by the gal vano- cautery snare ; but care must be taken to have this en- 
gage at the base of the growth, as section at a higher plane is apt, in 
spite of all precautions, to be followed by severe bleeding. With some 
of the larger growths an extensive dissection may be necessary to insure 
complete eradication. 

B. Malign^ant Growths. — Practically, all the malignant growths in 
the region under consideration may be classified as either lymphoma, 
sarcoma, or carcinoma. 

Primary malignant lymphoma is of very rare occurrence in the 
pharynx. According to Honsell ^ and Jardon/ but seven cases have been 
recorded. Mamlok has published the history of another,' occurring in 
a man aged sixty years. The case was regarded as inoperable, but tem- 
porary imx)rovement took place under the use of iodine externally and 
arsenic internally. 

The diagnosis of these growths lies between lymjihoma, sarcoma, and 
leukaemia. In leukaemia there are the characteristic blood- changes, espe- 
cially the increase of white cells and a marked condition of debility. In 
lymphoma the blood is normal, and in spite of these sometimes enormous 
tumors the patients remain for a long time in fairly good general con- 
dition. Sarcoma is of more rai)id growth and develops its own cachexia. 
Objectively, the two (sarcoma and lymphoma) present great similarity in 
their early stages, but examinations of sections of typical specimens from 
them will show a marked difference. Malignant lymphomata are true 
hyperplasise of the lymph -glands. The overgrowth of lymphatic ele- 
ments may attack a grou^D of glands suddenly, but remains strictly con- 
fined to the territory of these glands, so that the capsule is not broken 
through and the neighborhood of the group is not encroached upon. The 
extension of the growth follows the course of the lymj^h -stream, one 
gland after another becoming involved in the same chain. Microscopical 
examination shows an increase in the amount of connective-tissue frame- 
work as well as a great increase in the lymphoid elements, and the dis- 

1 Beitriige zur Klin. Chirurg., Bd. xiv. 

^ Bonner, Inaug. Dissert., 1888. 

3 Arch. f. LaryngoL, 1899, Bd. ix. S. 485. 



TUMORS OF THE PHARYNX. 



521 



tinction between cortex and medullary substance is no longer i^ossible. 
Finally, the trabecul?e become obliterated, owing to the colossal increase 
of lymph elements, which comi)letely fill the capsule. Sarcoma of the 
lymph-glands is made up of a heterologous structure, the specific prod- 
ucts being round and spindle-shaped cells. These have a tendency to 
break through the glandular capsule and to attack first the periglandular 
tissues, and later those more remote, including muscle, fascia, and skin. 
The tumor cxuickly becomes adherent to neighboring organs, and is more 
painful than lymphoma. Mixed forms occasionally occur. The symp- 



FiG. 194. 



i>5*rir->5'I«f?J.{ir^CvIi?-rS?£c*^^^^^ 










Lymphosarcoma of tonsil. (Seifert and Kahn.) a, epithelial covering; &, h. traces of follicles; c, c, 
spaces containing delicate fibrous tissue ; d, dilated vessel ; e, layer of apparently normal tissue. 



toms of the latter are mainly mechanical, and consist of gradual impair- 
ment of all the palatal functions. Growth downward affects the phj'sio- 
logical integrit}^ of the larynx. 

The only remedies which seem to have any effect on the lymphomata 
are iodine and arsenic. Iodine may be applied locally or may be injected 
in the form of the tincture directly into the mass. Injections of arsenic 
have been made in connection with its internal administration. The 
remedy should be given in small doses, gradually increased to the full 
physiological effect and then gradually decreased. The choice of prepa- 
ration seems immaterial. The question is merely as to what form of 
arsenic will be most easily borne by the stomach in each case. 

Sarcomata may involve either the soft palate or the tonsils and 
pharynx. Of the former, Bosworth has reported some twenty cases, and 
others are being published from time to time. They seem to manifest 



522 DISEASES OF THE PHARYNX. 

themselves here at an earlier age than when occnrring elsewhere in the 
pharynx proper. They are mnch more frequent in the male sex, a fact 
for which no satisfactory explanation has yet been given. No special age 
seems to be susceptible, about as many cases occurring before as after the 
fortieth year. All histological forms of sarcoma have been observed. As 
a rule, growth is slow. Symptoms first show themselves as impairment 
of vocal function and dysphagia. Unless early ulceration occurs, pain is 
not a prominent feature ; when it does occur, it may radiate to the ear. 
In some instances the growth has seemed to start from the posterior sur- 
face of the soft palate, and finally has overhung the larynx and caused 
suffocative attacks. Pharyngeal mucus is increased, and there sets in 
from the ulcerated surface, if such be present, a foul discharge. Bleed- 
ing is not common. Eliot^ reports one case of fatal hemorrhage, the 
growth being of the spindle- celled variety, occurring in a girl aged 
twenty-three years. As a rule, adenopathy does not take place until the 
tumor has definitely invaded neighboring structures. For years it may 
appear as a smooth, circumscribed mass, slowly increasing in size, with 
at times long periods of quiescence. Although In general appearance 
diagnosis from fibroma is impossible, the surgeon is assisted by the fact of 
the rarity of fibroma at this site and by the absence of pain in the latter. 

In a case of suspected sarcoma of the palate, potassium iodide should 
be given to exclude the possibility of a gummy tumor. In the light of 
modern surgery much is to be exiDCCted from early or even late inter- 
vention, for sarcoma of the palate does not seem to be especially malig- 
nant, at least so far as concerns rapidity of growth. This favoring cir- 
cumstance has been ascribed to the scantiness of lymphatic channels. 
As to details of removal, each case must be attacked along the lines it 
suggests, care being taken to encroach slightly upon surrounding healthy 
areas in order to make removal thorough and lessen the chances of recur- 
rence. In certain cases, where the extent of the growth makes operative 
intervention inadvisable, good results — even entire removal — have fol- 
lowed the injection of a combination of the toxins of the bacilli of ery- 
sipelas and of B. prodigiosus, according to the plan developed by W. B. 
Coley and others. Only the spindle- celled variety, however, seems to be 
affected favorably by this treatment. A notable success was reported 
some time ago by W. B. Johnson ; ^ but other observers, following iden- 
tically the same treatment, have reported complete failure. The plan is, 
however, worthy of trial. For the discharge, hydrogen dioxide followed 
by an alkaline antiseptic mouth- wash may be used. Hopeless cases call 
for opium to relieve pain. 

Symptoms of sarcoma of the tonsil may be referred to mechanical 
disturbance or may be ushered in by the features of a common angina. 

^ Illus. Med. and Surgery, 1882, vols. i. and ii. p. 107. 
2 New York Med. Rec, November 17, 1894, p. 616. 



TUMORS OF THE PHARYXX. 623 

The acute stage of the latter subsides, but the region of the affected 
tonsil is left tender, while the swelling persists and gradually encroaches 
upon the surrounding parts. Ulceration comes on relatively early, and 
hemorrhage is more common than where the growth is limited to the 
palate. The ulceration is accompanied by the usual offensive discharge, 
and glandular involvement soon becomes manifest. In one or two in- 
stances the deeper parts of the growth suppurated, the escape of pus 
temporarily abating the severity of the local symptoms. The general 
health deteriorates, and the cachexia of malignant disease soon comes on. 
Few cases live more than a year. 

The question of diagnosis depends upon the results of microscopical 
examination and the effects of the iodides. Treatment should be as indi- 
cated above, and, if possible, complete eradication should be undertaken. 
At times it is necessary to attack the growth from the outside, completely 
extirpating the cervical glands ; bacteriotherapy may also be tried. 
Chamberlain ^ reports a case of round-celled sarcoma of the tonsil in a 
man twenty-six years of age. Excision was j)erformed, but a raj^id re- 
<iurrence led him to try injections of toxins as above outlined. The 
result, though distinctly favorable, was, at the time the case was reported, 
not decisive. 

Eeported cases of sarcoma of the oropharynx number about thirty. 
In this situation the growth maj be pedunculated or have a base of mod- 
■erate size. The higher up in the x>harynx the slower the growth, as a 
rule, and the less the tendency to glandular involvement. It is usually 
of the si^indle-celled variety, and occurs more often in males after middle 
life. Symptoms are referable to obstruction of the pharynx, causing diffi- 
culty in breathing and swallowing. The prognosis is bad. If the base 
is small and accessible, removal may be attempted with the galvano- 
cautery snare ; but if it be broad and low down, it is better to gain 
access to it hj a lateral or subhyoid pharyngotomy. 

Carcinoma of the soft palate is uncommon. Bosworth (1892) enumer- 
rated thirty cases. The disease is more common in the later years of life, 
and almost without excei^tion has occurred in men. The cancerous 
growth shows a tendency here to confine itself to the palatal structures ; 
it probably originates in the epithelium lining the muciparous follicles. 
Irregular infiltration takes place into the surrounding structures, and 
ulceration is an early feature. When extension occurs, it is more com- 
monly in the course of the faucial pillars. 

Concerning the primary origin of cancer we have no definite knowl- 
edge. Modern investigations tend towards the parasitic theory, but 
whether the parasite is an animal or a vegetable organism is in dispute. 

Early symptoms are a loss of flexibility in the movements of the 
palatal muscles and a consequent impairment of the functions of swallow- 

^ Virginia Med. Month., June, 1895. 



524 DISEASES OF THE PHARYNX. 

ing and speech. Pain may not be severe at the outset, as the soft, yielding 
palate allows of considerable pressure before the patient begins to suffer. 
Later appear the ulceration, foul discharge, and cachexia. Hemorrhage 
from carcinoma confined to the soft palate is not common, and glandular 
enlargement may be absent until a late period of the disease. Dyspnoea 
is occasionally present, owing to the backward pressure of the growth, 
and tracheotomy may be required. 

In the absence of microscopical examination a diagnosis in the early 
stages between sarcoma and carcinoma is not always easy. In the former 
a circumscribed mass, slowly spreading, of soft consistency^, and rarely 
ulcerating, should be looked for. Opposite conditions will suggest the 
latter. As to adenopathy, it will be noticed that in both sarcoma and 
carcinoma this may or may not come on early, according to the confine- 
ment of the tumor to the palate. In carcinoma the extension of the 
growth is, unfortunately, rapid. 

Patients always die from this affection, though operative intervention 
may prolong life and render it more comfortable. Otherwise, the resources 
are limited to keeping the parts clean by the use of deodorizing antisep- 
tics and to keeping pain under control by local or systemic anodynes. 
Comfort in taking food may be obtained by the use of cocaine and the 
coating of the parts with orthoform in emulsion or mucilaginous suspen- 
sion. In carcinoma bacteriotherapy has not yielded the same good results 
as in sarcoma. 

Carcinoma of the tonsil occurs more frequently than sarcoma of the 
same organ. Here are found the squamous, alveolar, and columnar epi- 
thelial varieties, and also the ordinary stratified epithelioma in which the 
actively proliferating surface epithelium invades the underlying struc- 
tures in the shape of cylindrical masses. A second variety tends to spread 
sui)erficially, so that the cylindrical i)roj,ections are very short. This 
form is often mistaken for leucoplakia. Price Brown regards this variety 
as due to fatty degeneration of the surface epithelium, stating that, if the 
patch is not removed, desquamation may set in, with the final result of 
malignancy. This kind of patch is, however, more apt to invade the 
faucial pillars than the tonsil iDroper. In a third variety there is a ten- 
dency of the epithelium to invade the deeper structures individually. 
The alveolar form resembles the ordinary scirrhus, except that the stroma 
is less dense and the alveoli are larger. Lennox Browne has seen only 
one case of the columnar form, and in this case the cells grew inward and 
were arranged as single and double layers, appearing as irregular cylin- 
drical tubes embedded in small- celled infiltration tissue. 

The symptoms are the usual ones of a malignant tumor in this situa- 
tion, and have been sufficiently described. Differential diagnosis is pos- 
sible only by the use of the microscope, as the gross appearances do not 
always enable one to determine between sarcoma and carcinoma. The 
former more commonly has a smooth, while the latter may have a fun- 



TUMORS OF THE PHARYNX. 525 

gating surface. Prognosis and treatment are the same as for carcinoma 
of the soft palate. 

Carcinoma of the oroj^harynx is A^ery rare. Bosworth collated thirty- 
three cases, but in some the data given do not determine whether or not 
the growth, started in the oroj^harynx i^roper. About two-thirds of the 
cases reported were women, and, somewhat curiously, the disease at this 
site develoi^s relatively early in life. Local and general symj^toms are 
as already described. The cervical glands are quickly enlarged. Death 
generally results in from sixteen to eighteen months. Prognosis and 
treatment are as above outlined. Owing to early interference with deg- 
lutition, feeding becomes an embarrassing question, and nutritive enemata 
may be necessary. Interference with respiration may require an early 
tracheotomy. 



CHAPTEE IX. 

NEUROSES OF THE PHARYNX. 

These may conveniently be considered under the headings of sensory^ 
motor, and vascular neuroses. 

Sensory Xeuroses. — Anaesthesia of the i^haryngeal mucosa may 
result from central causes, such as cerebral hemorrhage, new growths, 
sclerotic conditions, and bulbar changes ; it occurs also after epileptic 
seizures, in the late stage of cholera, and in hysterical states. During the 
recent years of the influenza pandemics many cases due to the poison of 
this malady have come under observation. It may result from the use of 
the bromides, morphine, etc., and, indeed, the former class of remedies 
is frequently employed to quiet irritable throats for purposes of local 
examination and treatment. Occasionally associated with a true anaes- 
thesia is a subjective sensation, as of a furry substance in the mouth. The 
most common cause of all is the diphtheritic poison. One or both sides 
may be affected. 

Examination reveals absence of appreciation of chemical, tactile, 
thermic, and electric stimuli. The larynx frequently presents a similar 
condition. Eeflexes are correspondingly in abeyance. At times the con- 
dition is only a serious annoyance from the passage of ingesta into the 
nasopharynx ; at other times it may be dangerous from the likelihood of 
the passage of ingesta into the air-tract. Speech is, of course, more or 
less impaired. 

Treatment consists in the administration of strychnine, either inter- 
nally or by submucous injection, and the employment of the faradic or 
continuous current, according to the state of nerve integrity. Attention 
should also be paid to the general health. 

Paraesthesia may be a manifestation of hysteria. It often persists for 
a while after the removal of a foreign body, and it is frequently difficult 
to persuade patients that the offending material has been removed. The 
act of swallowing keeps up a certain amount of irritation at the site of 
lodgement, and healing may require some time, even in simple cases. Par- 
aesthesia may also be due to catarrhal conditions or to various abnor- 
malities of the lingual tonsil, giving rise to that symptom which Browne 
has so accurately described as ^ ' pharyngeal tenesmus. ' ' A similar feature 
characterizes the familiar globus hystericus. Many of these patients 
become hypochondriacal from reading medical books, etc., and have a fear 
of serious throat disease, especially diphtheria, or, in the case of those who 
have had syphilis, the reappearance of the local ulcerations. Kafeman ^ is 

^ Rev. Int. de RhinoL, 1893, vol. iii. p. 13. 
526 



NEUROSES OF THE PHARYNX. 527 

disposed to lay much stress on lymphoid hypertrophy in the vault of the 
pharynx as a cause of parsesthesia in both throat and nose. There are 
many cases, however, in which the most careful examination fails to 
discover any cause for the local symptoms. 

In addition to the removal of the exciting cause, the nerve tone of 
these patients should be im^^roved by the internal use of arsenic, phos- 
phorus, strychnine, etc. Cold affusions to the outside of the throat fol- 
lowed by brisk friction with a brush or a coarse towel are often of benefit. 
Careful attention should be x)aid to the diet and to the bowels, for many 
of these patients suffer from an autotoxremia arising in the gastro-enteric 
tract. Finally, it may be noted that catarrhal states of the epiglottis and 
arytenoid regions sometimes cause reflex disturbances referred to the 
pharynx, and these areas must not be overlooked in the search for an 
exciting cause. 

Hypersesthesia of the pharynx is constantly seen in clinical practice, 
and may arise from almost any cause of an irritative nature, either local 
inflammation, foreign bodies, states of increased nervous excitability, or 
as a reflex disturbance, especially from the digestive tract. It often pre- 
vents the simplest examination of the parts, when no actual disease can 
be discovered. This is particularly noticeable in those who use alcohol, 
tobacco, tea, coffee, etc., to excess. Most of these patients suffer from 
gastric catarrh. The mere protrusion of the tongue or even the thought 
of an examination often causes violent retching. Treatment suggests 
itself, — viz., the correction of any bad habit of eating or drinking, the 
free use of ice-pellets, and the administration of the bromides, which may 
be used as a gargle and then swallowed, enough being given to induce 
full constitutional effect. A cocaine spray may cautiously be used for the 
same pur^^ose. 

Pure neuralgias of the palate sometimes occur. The patients are 
generally women, who suffer from darting pains which start from sensi- 
tive areas that can be determined by probing. Light cauterization of 
these areas is often followed by relief. Aconitine may be given internally 
in doses of sh grain every three or four hours, its effect being carefully 
watched. Another type of the affection is sometimes found in young 
chlorotic girls. Such i^atients need iron, and applications of tincture of 
aconite or a mixture of chloral and camphor to which the aconite is 
added may be made to the iDalate. A time-honored and valuable com- 
bination is the mixture of one drachm each of chloral and camphor 
rubbed together till a fluid results ,• to this is added half an ounce of 
aconite, and the application is made with a camel' s-hair brush. 

Motor Neuroses. — Under the heading of ''perverse action" or 
' ' chorea' ' of the palate there may be placed a group of cases, all of which 
present the common feature of a rapid raising and lowering of the velum, 
without tensity of the latter. Other unusual features may be objective 
noises of various kinds. Thus the case is reported of an anaemic, nervous 



628 DISEASES OF THE PHARYNX. 

man who for two years had produced an objecth^e noise whenever he 
turned or bent the cervical spine. Examination showed rhythmical 
contractions of the palate, varying in rapidity from 90 to 105 per minute. 
The noises were audible both to the patient himself and to a by-stander, 
and sounded lite the grinding of teeth. Ostino^ reports the case of a 
physician who from his fourteenth j^ear had suffered from a subjective 
ticking sound, which could momentarily be arrested by a voluntary ef- 
fort, and was not especially troublesome, except at night. The velum 
was found to move synchronously with the pulse, and an observer could 
hear a distinct sound, though standing some two feet from the patient's 
right ear. On the left side the sound was audible only on close contact 
with the patient ; it continued during the movements of mastication and 
deglutition, but ceased when the tongue was depressed and the floor of 
the mouth fixed. These sounds are apparently due to the action of the 
levator palati muscle, and the exciting cause may be either changes in 
the region of the Eustachian tube or of a reflex nature. In reported 
cases, removal of lymphoid hypertrophy from the pharyngeal vault, 
cauterizations of the turbinates, etc., have all been followed by relief. 

It is often difficult to assign a cause for some of these cases. In that 
of Ostino, mentioned above, the sounds and movements temporarily dis- 
appeared during an acute coryza, because the congestion of the mucosa 
of the entire region imj)eded the action of the palatal muscles. The 
same physical condition resulted when the depression and fixation of the 
floor of the mouth antagonized their action. Similar palatal perversity 
is sometimes seen in the later stages of i)aralysis agitans. 

Muscular spasm in this region is not always confined to the palatal 
structures, but may extend to the constrictors of the pharynx and even 
to the upper part of the oesophagus. In these latter cases the nervous 
implication is prominent, and treatment should be directed in accordance 
with this fact. 

The most important motor neurosis is paralysis. The chief causes of 
this are diphtheria, degeneration of the medullary nuclei, pressure on the 
medullary nerves, or tumors pressing on the base of the brain. Loss of 
motion may be attended by partial or complete loss of sensation, as in 
ordinary cases of hemij)legia. Local inflammations may cause a serous 
infiltration of the muscular substance, resulting in a loss of power, though 
not a true iDaralysis ; so, also, varying conditions of neuritis may be 
induced by different toxins. 

Lecocq has given the histories of two young women with nasal voices 
and dysphagia, in whom there had been no antecedent diphtheria or in- 
flammatory condition. An affection of the facial nerve was considered 
impossible, owing to the absence of facial paralysis. (This view is, how- 
ever, erroneous, as the palate is supplied by the vagospinal trunk, not 

^ Arch. Ital. di Otol., 1900, vol. x. p. 26. 



XEUROSES OF THE PHARYXX. 



529 



tlie facial, p. 466.) l^o mesophalic or bulbar lesion could be determined. 
Lecocq called the condition ^ ' essential paralysis, ' ' due to neuritis starting 
in tlie nerve-fibrillse themselves, without extension from any neighboring 
organ. Medication and the continuous current were without effect, while 
the interrupted current led to a surprisingly quick recovery. 

In all these conditions of paralysis the palate is more or less flaccid, 
and is not comjiletely raised in either phonation or deglutition. In uni- 
lateral x)aralysis the arch of the fauces is distorted, being abnormally 
roomy on the affected side, and during phonation there is a distortion 
of the whole structure towards the sound side. In bilateral paralysis 
the uvula and the whole i^alate hang loosely, and move feebly or not at 
all, according to the degree of the i)aralysis. The simplest test of motility 
is to have the patient utter a sound of high pitch. In normal conditions 
the levators act strongl3\ Eeflex stim- 
ulation with the probe or a weak elec- Fig. 195. 
trie current will also determine the 
amount of loss of muscular power. 
In all of these states the vowel sounds 
have a twang which only the ^^n" and 
'^ug" sounds should have; also the 
failure to shut off the nasopharynx in 
forcing air through the mouth to pro- 
nounce ''p" and ^^b" makes of these 
respectively ^'f" and ^'v." In swal- 
lowing, the muscles of deglutition 
sometimes lose control of the ingesta, 
which consequently pass into the naso- 
pharynx and cause choking. 

In cases of loss of power of one 
vocal cord the x>alate is apt to be 
affected on the same side, and occa- 
sionally there is loss of power on the 

same side of the tongue, with more or less atrophy. This symptom- 
complex is referable to lesions of the anterior part of the medulla. As 
the tongue and cord lesions are manifestly due to lesions of the hypo- 
glossal and higher fibres of the spinal accessory nerves, Hughlings Jack- 
son, who first pointed out the association of these three paralyses, was led 
to believe that the palate received its innervation from one of these 
sources, a theory which has been fully confirmed by later anatomical 
studies. 

Paralysis of the constrictors of the pharynx is generalh^ due to either 
dij)htheria or bulbar lesions. Here the immediate danger is that of suf- 
focation from the passage of ingesta into the air- tube. 

All the foregoing conditions of paralysis call for the exhibition of 
iron, arsenic, phosphorus, and especially strychnine, together with the 

34 




Paralysis of left side of palate. (Bosworth.) 



530 



DISEASES OF THE PHARYNX. 



employment of the faradic or galvanic current, according to electrical re- 
action. Many of them are due to incurable lesions of some portion of 
the nerve-axis, and such patients should be made comfortable and, if 
necessary, fed through a tube. Cases referable to diphtheritic neuritis 
generally recover of themselves, but much can be done to hasten this 
result. The constant current is generally more serviceable than the in- 
terrupted ; the positive electrode should be placed over the cervical ver- 
tebrae, while the negative may be applied directly to the affected muscles. 
Vascular Keuroses. — A word may be added concerning vasomotor 
disturbances in this region. These generally take the form of what has 
been called by Striibing ''angioneurotic oedema.'' It is a vasomotor 
disorder, characterized by an abrupt cedematous swelling of variable ex- 
tent, occurring sometimes with gastro-intestinal crises. There seems to 
be a marked hereditary element in the affection, and a periodicity in 
the attacks is often noted. Death may occur from oedema of the larynx. 
Thomas Hubbard ^ reports the case of a woman thirty years of age, with 
attacks of faucial oedema which seemed to be the expression of a cumu- 
lative autotoxsemia. The patient was subject to peritonsillar swellings, 
which would come on suddenly and during their continuance prevent 
deglutition. They occurred twice a month for a i^eriod of two years ; 
the patient would be confined to bed for a couple of days, and the 
attack would then pass off. Starvation seemed to be the best treatment, 
and eliminative measures finally broke up the series of attacks. Patients 
who suffer in this way are usually of the lithsemic type. These affec- 
tions have sometimes been called giant urticaria, but Hubbard notes as 
differential jjoints that in angioneurotic oedema there is a definitely 
localized, persistent vasomotor instability, while in urticaria the area 
of attack is shifting, the attacks intermittent, and there seems to be a 
vasomotor irritability responding to certain irritants, probably from the 
gastro- enteric tract. 

^ Ann. Otol., Laryngol., and RhinoL, iS<^ovember, 1897, p. 425. 



CHAPTER X. 

DISEASES OF THE TYULA AND TONSILS. 

Malfoeimatioxs axd Axo^^ialies. — In three thousaud cases of throat 
diseases seen in routine practice, C. Berens ^ found eighty-four of abnor- 
malities. Typical instances of double uvula have been reported by 
Somers ^ and others. Lennox Browne ^ reports a case of double, and says 
that he has seen one of triple, uvula, — a central and functionally efficient 
one, with on each side a shorter i^rolongation not containing muscular 
fibres. 

Farlow has called attention to a condition of the uvula often mistaken 
for relaxation, — namely, an uneven or irregular development of the azygos 
uvul?e muscle. The organ hangs towards the side of the greater amount 
of muscular structure, simulating a paretic state. Watson records a case 
of varicose veins of the uvula and soft i:)alate, the former being nearly 
two inches long and made up of venous knots. Cohen has seen the 
enclosure of a uvula of considerable size in a fold of mucosa which was 
continuous with the anterior faucial pillar, extending horizontallj" from 
one tonsil to the other. Minor degrees of this latter anomaly are not 
uncommon. One case of cleft tongue with complete absence of the soft 
palate, occurring in a child seen at the eighth month, has been recorded 
by Helsham. Somers has called attention to uvular defects as stigmata 
of degeneration, quoting C. L. Dana as having found defects in either 
shape or innervation in very nearly fifty per cent, of all cases of degen- 
eracy examined. 

Spontaxeous H-EMATO^ia. — As a result of trauma, especially that 
due to operative intervention, hemorrhages into the substance of the 
uvula are not uncommon, but spontaneous hemorrhage is very rare. One 
case has been rei^orted by Ripault * in a man aged sixtj^ years, in whom 
the condition came on suddenly during the night, causing him much 
discomfort. Varicose enlargements were visible on the faucial pillars, 
while the vascular system i)resented uniform evidences of arterioscle- 
rosis. The swelling was presumably the result of mixture of a small 
vessel in the substance of the uvula. The obvious treatment in such a 
case is carefully to examine the condition of the vessels and to test the 
urine. A case of calculus^ of the uvula has been reported by Goodale.^ 

^Phila. Med. Bulletin, May, 1893. 

2 xew York Med. Jour., March 10, 1900, p. 341. 

3 Throat and Xose (ed. 1899), p. 320. 

* Ann. des Mai. de 1' Oreille, 1898, vol. xxiv. p. 463. 

5 Boston Med. and Surg. Jour., December 8, 1898, p. 571. 

531 



532 



DISEASES OF THE PHARYNX. 



Acute TJvulitis. — Acute uvulitis rarely occurs alone, but Is gener- 
ally one feature of a composite process which affects the fauces and phar- 
ynx. The mucosa at the tip of the organ is somewhat thicker and less 
compact than elsewhere in the mouth, and this condition favors exuda- 
tion, which is apt to assume the oedematous tyi^e. 

Etiology. — The affection generally results from trauma due to misdi- 
rected operative intervention iu the neighborhood, especially as a part 
of the reaction following operations on the tonsil, notably ignipuncture, 
even in cases in which the uvula itself has in nowise been injured. It 
may also arise from the ingestion of irritating food, from prolonged and 
excessive vocal effort, and from various forms of sepsis. 

Fathology. — The uvula becomes swollen and oedematous, and may, 
from the rupture of superficial capillaries, even bleed. Acute oedema 
is not infrequently seen in the later stages of phthisis and syphilis, and 
the organ may share in the more chronic hydrsemia of various visceral 
affections. An arthritic diathesis seems to predispose to inflammations 
of the uvula. 

Symptoms. — These are of the general sore throat variety, constitutional 
symptoms being of a mild type or altogether absent. The local discom- 
fort varies from a slight impediment to respiration and the feeling as 
of a mass in the fauces up to a pain of considerable severity. The voice 
has a muffled sound, and if the organ is long enough to reach the epiglottis 
there are added a muffled cough and possibly slight dyspnoea. 

Treatment. — In the milder cases, purgation by a mercurial, followed 
by a saline, together with the use of some simple astringent mouth-wash, 
will relieve the condition. Hot alkaline gargles are grateful during the 
acute stage. It is not recommended to remove at this time an undue 
length of the organ, but if the oedema is excessive it is proper to puncture 
or scarify and use antiseptic washes. It is scarcely necessary to say that 
the knife employed should be most carefully sterilized and have a fine 
point ; it is well also to hold the organ with a fine-toothed forceps or by 
means of a small spoon passed behind it, otherwise it is apt to slip away 
from the sharpest point. Suppuration of the uvula is rare. L. Yervaeck ^ 
has noticed in recent pandemics of the grippe many cases in which the 
throat lesions seemed confined to the uvula, which was swollen and 
oedematous. A special feature was a submucous hemorrhage coming 
on during the period of convalescence. 

Oheonic Uvulitis ; Hypeetrophied Uvula. — Simple chronic uvu- 
litis is merely one element in the general condition of chronic inflamma- 
tion of the entire faucial tract. Very few patients pass through a siege 
of chronic sore throat without the sequel of a more or less enlarged 
uvula. Vocal use during a period of acute inflammation is apt to lay 
the foundation for its development, and it is especially associated with 

^ Jour, de Med., 1899, No. 14. 



\ 

\ 

\ 

DISEASES OF THE UVULA AND TONSILS. 533 

chronic gastric disturbances. Other causes are the same as those in- 
ducing acute inflammation. 

Failiologij. — Lennox Browne notes four varieties of change, — fibroid, 
mucoid, vascular, and glandular. Bearing in mind the structure of the 
organ, it is easy to see how the mucosa may prolapse on the underlying 
muscular cylinder and present itself as a pointed tij) of a pearly white 
color and an oedematous consistency. Sometimes the muscular cylinder 
itself is hypertrophied, but the enlargement usually consists of an in- 
crease in the bulk of the organ rather than a simple elongation. In 
some cases of the latter class the organ is so long that it reaches the 
dental arcade in front and the entrance of the larynx behind. 

In this condition the striated muscular fibres undergo degeneration, 
showing, according to Hoen,^ marked proliferation of their nuclei and, 
in the later stages, a disappearance of the contractile substance to a 
greater or less degree. The veins are enlarged, the arteries are diminished 
in size, and the surface epithelium is thickened. Earely the glandular 
hypertroi3hy forms the bulk of the organ, and groups of leucocytes be- 
neath the surface suggest recent inflammatory changes. 

Symptoms. — These are of all grades of severity, and do not necessarily 
correspond with the size of the uvula. Some patients with enlarged 
uvula present no symptoms at all, but the majority complain of tickling, 
hacking cough, retching on slight ijrovocation, and occasional vomiting. 
As special excitants of these outbreaks maj^ be mentioned sudden changes 
of temperature (even the cold bath) and fatigue. Sometimes during 
sleej) the faucial relaxation brings the tip of the organ in contact with the 
entrance to the larynx, and the patient wakes with a sudden laryngeal 
spasm. The constant cough may cause rupture of some of the superficial 
vessels either of the uvula itself or of the surrounding structures, and 
tends still further to elongate the organ. The appearance of blood-streaks 
in the expectoration and the exhaustion attendant on coughing often lead 
to a suspicion of i)ulmonary disease, especially as the condition is accom- 
panied by considerable debility, patients often losing much flesh and 
strength from this trivial ailment. As a result of hypertrophied uvula 
and consequent impaired action of surrounding muscles, singers experi- 
ence a loss of vocal range, early fatigue, and sometimes an annoying 
tremolo upon the attempted production of any forced tone. 

Treatment. — Any associated catarrhal state should be treated as for 
an acute condition, and, if necessarj', a portion of the uvula removed. 
This operation has often been abused in the past, but recently there has 
been a reaction against over-zealous surgical procedures. Astringents 
may profitably precede surgical intervention, but their effects in pro- 
nounced cases will be but temporary, and on their cessation the old train 



^ Jour. Exp. Med., vol. iii. p. 551. 



534 



DISEASES OF THE PHARYNX. 



of symptoms will reappear. Mild cases of elongation may j^ermanently 
disappear if the stomach be regulated. 

From a surgical point of view the main question is, Granted that uvu- 
lotomy is necessary, how much of the organ should be removed ? In the 
adult the uvula measures, on the average, three-eighths of an inch in 
length, and, with the mouth closed, should hang free in the fauces, not 
touching the tongue. Before making an estimate of the amount of tissue 
to be removed it is essential that the part be at rest in a normal iDosition, 
otherwise the soft palate will be raised and the uvula along with it, 
thereby distorting natural relations. 

Fig. 196. 




Operation of uvulotomy. (Bosworth 



The operation of uvulotomy or staphylotomy is often performed by the 
general practitioner, and hence is here described in detail. Anaesthesia 
is easily obtained with a ten per cent, cocaine solution, applied in spray 
or on a cotton carrier. The tongue is depressed with an instrument 
(preferably Tiirck's) held by the patient (Fig. 174), the tip of the organ 
is drawn forward with a pair of fine-toothed forceps, and the section 
made either with one of the uvulotomes in common use or with a pair 
of long-handled scissors curved on the flat side. 



DISEASES OF THE UVULA AND TONSILS. 



535 



Care should be taken to make the section in such a way as to bevel the 
organ on its posterior surface. Food is thus prevented from coming in 
contact with the raw surface, and the drip of the secretions from above 
is facilitated. Pieces of ice held in the mouth lessen the after-smarting. 

Fig. 197. 




Sajous's uvuJotome. 

The uvula will contract somewhat after section, and this fact must be 
taken into account in estimating the amount of tissue to be removed. 
The latter, at times, consists mainly of thickened mucosa, but there may 
be cases in which it is advisable to remove a portion of the muscular 

Fig. 198. 




Seller's uvula scissors. 

cylinder. Bleeding is but slight, and generally ceases on the use of the 
familiar gargle of gallic and tannic acids (gallic acid, 1 part -, tannic acid, 
3 parts ; water, 4 parts ; which on being shaken makes a viscid mixture, 
and should be held in the mouth without dilution or should be sipped). 
The shorter the stump the more likely is bleeding to occur. For an ex- 
haustive review of the literature of this complication the reader is referred 
to an article by the late E. C. Morgan.^ 

De Blois advocates for this operation the use of the galvano-cautery.'^ 



^ Trans. Amer. Laryngol. Assoc, 1886, p. 80. 



=^ Ibid., 1893, p. 108. 



536 DISEASES OF THE PHARYNX. 

He employs a fixed loop, purposely avoiding one whicli can gradually 
be tightened, and wliich will not leave a straight surface and continuous 
bevel. As soon as the cautery is felt on the posterior surface of the 
uvula it is drawn tight by the reflex action of the palatal muscles, and 
by traction with forceps in the opposite direction the operator can bevel 
the cut very easily, so that when the wound has healed the stump will 
retain the normal tapering shape rather than the bulbous end frequently 
left after the use of the scissors. 

DISEASES OF THE TONSILS. 

A^iatomy. — The general situation of the faucial tonsils has already 
been mentioned (p. 463). The most logical view of the association of the 
various tonsillar structures is that which regards them as localized en- 
largements in the course of the so-called ''tonsillar ring'' of Waldeyer.^ 
By this term is meant that irregular circular continuity of lymphoid 
tissue which starts in the nasopharynx and stretches on each side to the 
edges of the Eustachian tubes, thence to the posterior surface of the soft 
palate, to the space between the faucial pillars (forming here the faucial 
tonsils), and finally unites in the fourth or lingual tonsil, which lies on 
the floor of the tongue between the circumvallate papillae and the epi- 
glottis. Similar deposits are found in the ventricle of the larynx and 
in the nasal mucosa. 

The faucial or palatal enlargements of the ring average from twenty 
to twenty-five millimetres in height and fifteen millimetres in breadth. 
They are irregularly oval in shape, limited above by the approximation 
of the faucial pillars, but extend a variable distance below. They cor- 
respond to the anterior x>ortion of what is called the ^ ' i^haryngomaxil- 
lary interspace," — that is, the space between the lateral pharyngeal wall, 
the internal pterygoid plate, and the upper cervical vertebrae, lying 
almost directly back of the pharyngopalatine arch. This interspace is 
filled with connective tissue. Under normal circumstances the tonsils do 
not protrude beyond the plane of the faucial pillars ; free on their inner 
side, they are in relation on their outer with the amygdaloglossus and 
styloglossus muscles and a few fibres of the posterior pillar. According 
to F. C. Cobb,^ outside of these few small fibres a hard fibrous wall about 
one millimetre in thickness is found, irom which septa run into the tonsil, 
this wall forming its capsule. Continuing from within outward, the supe- 
rior pharyngeal constrictor and the buccopharyngeal fascia are succes- 
sively met. This fascia forms the inner wall of the pharyngomaxillary 
space. In the posterior part of the latter are the large vessels, and cor- 
responding to its anterior part are the tonsils. These relations are of in- 
terest as bearing on the position of the carotid arteries, which are a 

^ Deut. Med. Woch., No. 20, 1884. 

2 Boston Med. and Surg. Jour., July 27, 1899. 



DISEASES OF THE UVULA AXD TOXSILS. 



537 



definite distance outward from the vertical plane of the tonsils as well 
as behind them, the distance from the lateral periphery of the tonsil being 
for the internal carotid one and a half centimetres and for the external 
two centimetres. 

Siq)rato)isiUar Fossa. — Considerable has been written of late years con- 
cerning the so-called supratonsillar fossa. This fossa is undoubtedly 
the i:)oint of entry of much of the contagion gaining access to the system 
through the tonsillar structures. It is a space lying at the upper part 
of the tonsil close to the anterior palatine arch, and was first described 
by His in 1885, and more recentlj' by Paterson.^ It has sometimes been 
mistaken for a large crypt, but is re- 



FiG. 199. 



// 



/ 



^^ 




ally not a cryi^t at all, being formed 
in an entirely different manner. From 
the free border of the palatoglossus 
muscle there arises a fold of mucosa 
stretching backward towards the 
tonsil, which it jpartially covers. 
His names this the plica triangu- 
laris. Its apex blends with the to^^ 
of the faucial arch and becomes lost 
in the velum palati, the base disap- 
pears in the structures at the base of 
the tongue, while the free edge con- 
tinues over the tonsil, which may, and 
often does, adhere to it. At the top 
of the tonsil and immediately behind 
the plica a curved probe may be 
passed into a cavity which extends 
for a variable distance behind the soft 
palate. This is the supratonsillar 
fossa or palatal recess, comprising the 
remains of the lower part of the orig- 
inal second visceral cleft. 

The connective tissue of the reticulum of the tonsils and the follicles 
lying therein are in structure exactly like the ordinary lymph-nodes. In 
the reticulum lymph-spaces may be seen between the follicles or on their 
periphery, these not being shut off as in the ordinary node. These lymph- 
si^aces are continuous with the afferent lymph-vessels which lie in the peri- 
tonsillar connective tissue. The tonsils are at the period of their greatest 
activity about the twenty-fifth year ; from that time they atrojDhy and 
assume atyj^ical shapes. aj)pearing as irregular hard masses apparently 
without any distinct diverticula. This change may be the result of the 
inflammations of preceding years or it maj' be due to senile degeneration. 




Right supratonsillar fossa, with plica pulled 
forward and upward. (Paterson.) 



^ Jour. Laryngol., 1S98, vol. xiii. p. 165. 



538 DISEASES OF THE PHARYNX. 

Also, the continued impact of food will tend to harden the cortex so as 
to make a sort of indurated rind, while the interior remains soft and 
pulpy. If the organ has been often inflamed, coarse connective-tissue 
septa are seen running through it. 

Physiology of the Tonsils. — The epithelium, which is of the squamous 
variety, is being constantly shed in health and with great rapidity in 
disease, so that in some places it may be, at times, only one or two layers 
deep. It was formerly supposed that the intact epithelium prevented any 
absorption of infectious or other material, but this view is no longer tena- 
ble. Goodale^ has introduced particles of carmine into the crypts of 
more or less hypertrophied human tonsils, and then, after a lapse of some 
time, removed the organs, subjecting them to microscopical examination, 
and found that absorption normally exists in the tonsils and takes place 
through the mucous membrane of the crypts. 

Goodale "^ has suggested the possibility of treating enlarged cervical 
glands by means of iodine introduced into the tonsillar crypts, the remedy 
following the normal course of the lymph-stream. It must be admitted, 
therefore, that the tonsils are capable of absorbing all sorts of material 
from the mouth. When it is considered that in health the flora of the 
human mouth includes more than one hundred different organisms, it is 
not strange that the tonsils are in a constant state of siege, and that some- 
times the enemy breaks down the barriers. 

Much difference of opinion still exists as to the exact function of these 
organs. Perhaps the most reasonable view is that which assigns to the 
entire ring of Waldeyer, which stands as an outer sentinel about the en- 
trance of both the air- and food- tracts, the role of a defensive organism, 
but whether this defence is by means of a phagocytosis or by other factors 
is still unsettled. Undoubtedly the muciparous follicles of the lacunae 
help to lubricate the bolus of food. Still further, the structural relation 
of the tonsils to the general lymphatic nodal bodies suggests that they 
may, like so many of the so-called ductless glands, have an internal secre- 
tion of their own. 

Development of the Tonsils. — The anterior palatal arch is derived from 
the second visceral arch, which forms the dividing-line between the mouth 
and the pharynx. Below the soft palate the faucial tonsil is formed by 
the development of lymphoid tissue in the cleft between the second and 
third arches, the upper part of the space being the supratonsillar fossa. 
Between the fourth and fifth months of foetal life the anterior or palatal 
arch widens and forms the free edge of the plica triangularis. According 
to Kolliker, at the fifth month of intrauterine life the tonsil is a smooth 
sac with fissure-like openings and several small cavities ; its internal or 
mesial aspect is that of a valve, the latter evidently being the plica. 

1 Arch. f. Lar., Bd. vii. S. 90. 

^ Boston Med. and Surg. Jour., 1898, vol. cxxxviii. p. 465. 



DISEASES OF THE UVULA AXD TOXSILS. 



539 



Lymphoid tissue forms in the sinus or groove and almost fills it, thereby 
constituting the tonsil (Paterson). 

According to Eetterer, the first steiD in the development of the tonsil 



into the hypoblast ; the result 



Fig. 200. 



In the 
is 
them 



from the general sur 



of 



consists in the ingrowing of the epiblast 
being ^ a group of diverticula 
formed from the ei^ithelial 
layer of the mucosa, the walls 
of which contain muciparous 
glands and lymph -follicles. 
These diverticula open in a 
uniform manner on the surface 
of the mass. The various 
tonsil groups differ from one 
another only in the arrange- 
ment of these diverticula : in 
the lingual tonsil they are sin- 
gle, but in the pharyngeal aud 
faucial, comi^ound. 
latter their 
such that a number 
recede 

face of the group to which 
they belong, and in this way 



is formed a chamber called a 
crypt or lacuna. The real 
significance of this anatomical 
term should carefullj^ be borne iu mind, for in recent medical literature 
it has lai'gely sui)i)lanted the word follicle as ax^plied to tonsillar inflam- 
mations. Inflammation of the follicle is only one part of the lesion in 
the malady termed "follicular'' tonsillitis. The follicle is not the diver- 
ticulum, but only one of the structures in the wall of the latter. 

Acute Tonsillar Inflammations. — Under this heading will be 
considered acute superflcial or catarrhal tonsillitis, acute lacunar tonsil- 
litis, acute parenchymatous tonsillitis, acute croupous tonsillitis, and 
acute suppurative tonsillitis. The latter (quinsy) is at its culmination 
partly a circumtonsillar afl'ection, though it may, and most often does, 
result from intratonsillar infection. Some of these forms may run into 
one another and represent different grades of severity of the infection. 

Acute Catarrhal Tonsillitis. — This is an acute inflammation 
which expends itself mainly on the mucosa covering the surface of the 
tonsil, and does not extend to any marked degree into the lacunae. It 
occurs more commonly in children, and is often one element in a general 
faucitis and pharyngitis. 




Development of the tonsil. (Retterer.) 



^ Harrison Allen, Trans. Amer. Laryngol. Assoc, 1S91, p. 12. 



540 DISEASES OF THE PHARYNX. 

Etiology. — Many attacks are referable to sudden changes in tempera- 
ture ; others are due to irritation directly, as from ingesta, or indirectly 
from bad gastro -enteric conditions. This latter cause is perhaps the most 
common. The affection is also seen in many of the contagious diseases 
of early years. 

Fatliology. — This is the simplest form of catarrhal inflammation of a 
mucous membrane, the latter at first becoming swollen and dry ; later the 
secretion is increased in quantity, and with its re- establishment the swell- 
ing subsides. In the mouth of a young child it is difficult to distinguish 
these different stages, and there is apparent only a diffused redness and 
swelling. The secretion may appear as a pasty mass. The foregoing 
condition may subside without incident or go on to a more severe form 
of inflammation. 

Symptoms. — These begin with a slight febrile movement and some dis- 
comfort in swallowing, together with i)ain and stiffness in the cervical 
muscles. Actual torticollis is not unknown. Pain may radiate to the 
ear, and in severe cases there may be some impairment of palatal func- 
tion. Examination shows that the above condition is not actually lim- 
ited to the tonsils, but extends more or less over surrounding structures. 

Treatment. — At the outset the bowels should be moved by a mer- 
curial and saline. If seen early, the tonsil may be touched with a solu- 
tion of silver nitrate, thirty grains to the ounce. Guaiacol diluted in an 
equal amount of glycerin is also useful for this purx)Ose, but care should 
be taken that none of the solution drops from the cotton carrier into the 
lower part of the throat. If the pasty secretion is troublesome, it is. 
best removed by a spray of equal parts of hydrogen dioxide and lime- 
water. Internally, small and frequent doses of aconite and belladonna 
may be given, or the time-honored mixture of muriate of iron tincture in 
glycerin, which has held its own against the great number of remedies 
introduced by modern therapeutics. If the case is seen early, such a 
plan will often abort the attack, but, as a rule, cases do not come under 
observation until well under way. Under these circumstances the diox- 
ide spray must be continued, and, with a view of making the patient 
comfortable, some of the new synthetic compounds^ such as lactophenin^, 
phenacetin, etc., should be given every two hours in dose proportionate 
to age^ care being taken to note the effect on the heart's action. A small 
dose of caffeine citrate may be added if the heart is at all weak. As a 
rule, this form of tonsillitis lasts but four or five days, and patients fre- 
quently get well without any treatment whatever ; but prompt interven- 
tion often wards off a more severe form of inflammation and renders the 
patient more comfortable, even though the duration of the affection may 
not be shortened. 

Acute Lacunar Tonsillitis. — This is often associated with the 
parenchj^matous form, and is the '^ulcerated sore throat" of the laity. 
It consists of an inflammation of which the most striking objective feature 



DISEASES OF THE UVULA AND TONSILS. 541 

is the filliug of the tonsillar crj^ts with whitish plugs, together with a 
general swelling of surrounding parts and a distinct febrile reaction. 

Etlologi). — The exciting cause most frequently given is exposure to cold, 
but it must be premised, in the light of our i^resent knowledge, that this 
phrase has in its literal interpretation become meaningless. Taking cold 
implies a lessened power of resistance to the various morbific influences 
against which the body constantly contends, and its causative agency in 
the j)roduction of disease is, therefore, an indirect one. The flora of the 
mouth is very extensive, and constantly contains germs of a pathogenetic 
nature. Ordinarily, these are non- virulent, or may be rendered innocu- 
ous by the sterilizing properties of the buccal fluids ; in other words, a 
sound condition of the general system nullifies their influence for harm. 

A disordered condition of the stomach is responsible for many attacks, 
especially that grou^) of symptoms known collectively as '^ biliousness," 
and predisposing factors are also found in the rheumatic and gouty diath- 
eses. For some years the writer has studied the question of rheumatic 
sore throat, and, in his judgment, the imi)ortance of this factor has been 
overestimated. Out of nearly six hundred cases of common throat in- 
flammation carefully observed with reference to this influence, he was 
unable to find any evidence of either family or personal taint in more 
than twenty-six per cent, of the i)atients, and he cannot understand the 
statements of Haig Brown and Fowler, whose figures are fiftj^-four i^qv 
cent, and eighty per cent, respectively. On the other hand, it must be 
admitted that so long as the exact nature of the rheumatic poison is not 
positively known, just so long will men diffej? as to what is and what is 
not a rheumatic manifestation. Of late much has been written concern- 
ing the tonsils as portals of systemic infection, and this is commendable 
as directing attention to a vulnerable area, for Gerhardt has called the 
tonsil a ' ' physiological wound, ' ' a definition taking account of the gaj)S 
in its epithelial covering. But many of the cases of infection which 
come through tonsillar portals, and which are looked upon as rheumatic, 
do not, in the writer's opinion, belong in that categorj^ ; they are sim- 
ply evidences of endocardial and joint infection. While the brunt of 
the rheumatic attack is borne by these structures, rheumatism is by no 
means the only factor in infection. 

Hoi)e says ^ that ' ' if a local acute manifestation of rheumatism occurs, 
it might, under ordinary circumstances, preferably be looked for in a 
serofibrous, not a mucofibrous, tissue, such as constitutes the tonsil, unless 
it is conceded that the tonsil assumes the role of a selective area." He 
goes so far as to say that it is ^ ' rare to meet with examples of recurring 
angina in those who carry recent or present unmistakable evidence of a 
rheumatic attack. In other words, the predisposition bears, if anything, 
a diminished ratio to the average individual, owing no doubt to the more 

^ Trans. Amer. Laryngol. Assoc, 1895, p. 58. 



542 DISEASES OF THE PHARYNX. 

than usual care exercised to guard against exposures and excesses." He 
also calls attention to the fact that, while tonsillar inflammations become 
less common as age advances, rheumatic and gouty manifestations become 
more common. There is a possibility that malarial poison may cause 
tonsillitis. Chassaignac has seen cases in which there was a i)eriodical 
exacerbation after painful symptoms, which, however, yielded promptly 
to quinine, though not responding to the usual methods of local treat- 
ment. 

Chronic enlargements of the tonsils naturally invite recurring acute 
attacks. In some instances the latter are coincident with suppressed 
menstruation, which condition is supposed to lower the normal power of 
resistance to infectious organisms. Inflammation may also be excited by 
the irritation of foreign bodies and by exposure to the odors from defec- 
tive drainage, which may be regarded as the type of a wide range of 
septic influences. Attendants in hospitals are frequent sufferers. The 
disease occasionally follows ox)erations on the intranasal tissues, especially 
galvano- cauterization, not often from cutting instruments. The reason 
assigned is, that for a time after cauterization the filtering action of the 
nares is in partial abeyance, and that some of the bacteria in the upper 
air-tract are stimulated to an abnormal virulence. 

Finally, there can be no doubt that certain foods, especially milk, 
may be carriers of contagion which may cause outbreaks of lacunar ton- 
sillitis. Interesting testimony on this point is ofiered by Grey- Edwards 
and Severn.^ They reported a series of cases in families all supplied 
with milk from the same farm. Bacteriological examinations of scrapings 
from the throats showed the presence of the staphylococcus pyogenes 
aureus and short streptococci, Klebs-Loffler and tubercle bacilli being 
absent. The milk-supply from different animals was then tested, and 
suspicion finally fell on one cow, whose milk was found to contain the 
same micro-organisms as those from the throats 5 pus-cells were also 
present. A change in the milk-supply at once checked the outbreak 
of tonsillitis. Other similar epidemics have been reported. It has 
been suggested that it is possible for the germs of scarlet fever to pass 
through the system of the cow in a modified form, so as to set up in man 
a milder and no n- infectious simple tonsillitis. 

It is a disputed point whether lacunar tonsillitis should be regarded 
under all circumstances as a contagious disease, though it seems so to be. 
Cases of direct contagion are often explicable on the ground of successive 
exposure of different members of the same family to the same unfavor- 
able environment. Under such circumstances the period of incubation 
is about four days. 

Pathology . — Either one or both tonsils may be affected. They are red- 
dened and swollen, while the surrounding tissues are more or less cedema- 

1 Brit. Med. Journ., 1897, vol. ii. p. 339. 



\ 



DISEASES OF THE UVULA AND TONSILS. 



543 



Fig. 201. 



tous ; this oedema is usually especially marked iu the soft palate and 
uvula, the latter being pushed to one side. The tonsillar crypts are filled 
with plugs composed of leucocytes, epithelial debris, various organisms, 
and possibly a little fibrin. Bacteria are more common at the mouth of 
the crypt, the bottom often being free from them. The leucocytes are 
poly nuclear neutrophiles, many of them containing bacteria. 

As to bacteriological findings, both staphylococci and streptococci 
are present. Frankel/ believes that the latter are the infectious ele- 
ments. E. Meyer^ found, in fifty-two 
cases, fourteen with staphylococci, gen- 
erally aureus, twenty-four with a mixed 
culture of the two, and fourteen with 
streptococci in pure culture. A dip- 
lococcus resembling, and perhaps iden- 
tical with, that of pneumonia has also 
been found. The varying proportion of 
these different micro-organisms causes 
no appreciable variation in the clinical 
features of the disease. Meyer's studies 
show that in normal conditions the se- 
cretion removed from the tonsils usu- 
ally contains a coccus resembling the 
streptococcus pyogenes, staphylococci, 
and leptothrix growths. Hilbert' 
found the streptococcus so universally 
present that he is unwilling to concede 
its etiological relation to tonsillitis, but 

regards its ]3resence in the deposits of inflamed tonsils as merely secondary 
and accidental. He thinks that it may flourish iu these deposits, and 
maj" find a way through the inflamed tonsils into the circulation and thus 
give rise to a general infection. 

In very young children the lacunar symptoms are often overlooked, 
but close inspection of the fauces in many of the febrile attacks of in- 
fancy will show the tonsils studded with pin-point deposits, which are 
cryptic plugs so small that they are hardly visible. 

Acute Parenchymatous Tonsillitis. — The conditions described 
in the foregoing paragraphs may be present without any enlargement of 
the tonsil as a whole ; often, however, it becomes greatly increased in 
size from the exudation of inflammatory products into its substance, pre- 
senting what is really a combination of the lacunar and parenchymatous 
forms, or the organ may be swollen while the crypts are clear. 

A careful study of the changes seen in these two types of tonsillar 




Acute lacunar tonsillitis. (Griinwald.) 



^ Arch. f. LaryngoL, Bd. iv. S. 130. 

3 Deut. Med. Woch., 1899, No. 43, S. 262. 



2 Ibid., S. 66. 



544 DISEASES OF THE PHARYNX. 

disease has been made by J. L. Goodale.^ He finds two varieties of 
lesions. The first is a diffuse proliferative change, the follicles being 
enlarged from an increase of their lymphoid cells and of the endothelial 
cells of the reticvdnm. Scattered along the latter are varying numbers 
of large phagocytic cells, which in some sections appear in irregular 
shapes, suggestive of amoeboid coDditions. They contain in their interior 
numerous cell-fragments from lymphoid or red blood-disks, the inter- 
follicular regions showing a similar increase of proliferation and lym- 
phocytes with occasional phagocytic cells. As the section is made in 
the deeper planes of the organ towards the mucosa, the cytoplasm of 
the lymphoid cells becomes more abundant, while their nuclei are more 
coarsely granular and lie eccentrically. Polynuclear neutrophiles are 
scattered through the interfollicular region, and may occasionally be 
seen escaping through the walls of the blood-vessels ; nowhere are they 
collected into groups. The cells of the mucosa show an active prolif- 
eration and exfoliation. 

A second variety of lesion found by Goodale in four out of sixteen 
cases examined is that of small abscesses beginning in the interior of the 
follicles, enlarging, and finally bursting into the crypts. In one of these 
cases a single small abscess was found only after examining many sec- 
tions, in two others about every tenth follicle was thus affected, while in 
the fourth nearly every follicle showed the minute sui3purating foci. 
This group of cases x)resented histories of inflammatory symptoms lasting 
from four to six days previous to the excision of the tonsil. 

The present tendency is to regard these forms of tonsillitis as of the 
nature of an acute infectious disease. Careful examination shows in 
many of them an enlarged spleen, albuminuria, various rashes, etc., fol- 
lowed at times by pleurisy, pneumonia, and irritation of the testes or 
ovaries. 

Symxjtoms. — The symptoms of both the lacunar and parenchymatous 
forms are practically the same. General manifestations may precede or 
follow the local. The former assume the type of an acute infection. 
There is generally more or less chilliness, followed by a ra^Did rise of tem- 
perature (104° F.), with corresponding changes in pulse-rate and respira- 
tion. Headache, constipation, thirst, anorexia, general malaise, and 
bodily ]3ains soon occur, with an amount of prostration out of all i3ro- 
j)ortion to the apparent severity of the local condition. It has truly been 
said that there is no surface of equal size in the whole body the inflam- 
mation of which is attended by such severe disturbance as is the area of 
the tonsil 5 in bad cases there may be clammy sweating, restlessness, in- 
somnia, and even delirium. The local symptoms begin with a burning 
or pricking feeling, which soon passes to actual pain, and it becomes 
increasingly difficult, especially when the tonsil is enlarged, to open the 

2 Jour. Bost. Soc. Med. Sci., January, 1899. 



DISEASES OF THE UVULA AND TOXSILS. 545 

montli. The cervical glands may be swollen and painful, the pain radi- 
ating to the ear, and partial blunting of the senses of hearing, smell, 
and taste is not uncommon. From the local swelling a sense of suffoca- 
tion may result, and be most distressing. The throat fills with a thick, 
tenacious mucus, and attempts at its removal by clearing the mouth or 
by swallowing greatly increase the patient's distress. Speech becomes 
thick and may be indistinguishable, the tongue is coated, and the breath 
offensive. Taking of food becomes agonizingly painful, and fluids may 
regurgitate through the nose from abrogation of palatal function. Per- 
sistence of the fever occasionally brings out an erythema which is some- 
times mistaken for that of scarlet fever. 

Differential Diagnosis. — Scarlatinal throats sometimes present lacunar 
deposits, but the disease is usualh^ ushered in with vomiting. The ques- 
tion is settled by the appearance of the characteristic exanthema in 
twenty-four hours, the latter being inore diffused and j)ersistent than is 
the simi:>le fugitive erythema of a febrile state. The faucial congestion 
in scarlet fever is generally much more extensive than in tonsillitis, 
though the actual swelling is less; the '^ strawberry tongue" of the ex- 
anthema is also of use in forming a conclusion. 

In syphilitic sore throat, which may present febrile symptoms, the 
redness is generally sj^mmetrically distributed, the congestion is of a 
duller red color, and the pain is not severe, — in fact, maj" be absent. It 
is from the superficial or catarrhal form of tonsillitis that specific dis- 
ease requires differentiation. Careful inquiry should be made regarding 
a possible syphilitic exj)osure. 

From diphtheria the diagnosis is at first by no means easy. Beyond 
all question there may be a diphtheria confined to the lacunjje, on the 
walls of which the exudate appears ; to the eye and in its clinical mani- 
festations it resembles the lacunar form of tonsillitis, and a positive de- 
cision must rest u^^on bacteriological findings. Doubtless many of the 
cases of reported contagion in lacunar tonsillitis have been actual di^^h- 
theria. In dii^htheria the exudate is apt to appear in larger patches, 
usually begins on the velum and uvula, is generally of a grayish hue, and 
is of a more ragged api)earance. In X3ure tonsillitis an ai)iDarent exu- 
date may be brushed off, as it is only mucus which by the action of 
the palatal muscles has become evenly diffused over the tonsils, sug- 
gesting a true dii)htheritic membrane. A bleeding surface after removal 
is no proof of true (Loffler) diphtheria, but only of a croupous inflam- 
mation, — that is, an exudation with degeneration or death of tissue. Ac- 
cording to Heubner (quoted by Schech), it is "• not at all imiDossible that 
spasm of the sui^erficial capillaries of the pharynx (excited reflexly by 
cold) may be followed by complete cessation of the circulation and 
croupous exudation." 

Course and Duration, — The duration of either form is from one to four- 
teen days, the average being five or six. The prognosis is good, though 

35 



546 DISEASES OF THE PHARYNX. 

a few cases have resulted fatally from supervening oedema of the larynx. 
If tlie affection frequently recurs the tonsils may become permanently 
enlarged; and there is always danger of quinsy. 

Treatment. — If the disease is seen at the outset it may be aborted by 
thorough purgation and painting the tonsils with pure guaiacol, strong 
cocaine solutions^ silver nitrate (fifteen per cent.), or by frequent spray- 
ing with solution of suprarenal extract or its active principle, adrenalin. 
After exudation has occurred the latter is of no use whatever, and simply 
aggravates the dryness of the throat, thereby increasing the patient's 
discomfort. Small and frequent doses of aconite and belladonna or of 
opium may be given. Emil Meyer advises the use of morphine, one- 
twenty-fourth grain, with Norwood's tincture of veratrum, two and one- 
half minims, given hourly for three hours, then less frequently 5 his 
experience has led him to believe that this combination is a tolerably 
sure preventive against the progress of the case towards suppuration. 
Another familiar combination is that of the 'tonsillitis" tablet triturate, 
each one containing tincture of aconite, one-fifth minim ; tincture of 
bryonia, tincture of belladonna, of each, one-tenth minim ; red iodide 
of mercury, one-one- hundredth grain. Of these one may be taken hourly 
for three hours, and one every three hours thereafter until the subsidence 
of the inflammation. Care must be taken to watch the effects of the mer- 
cury. At the outset cold compresses may be applied to the neck, while 
if the case has fully developed, hot applications are generally more grate- 
ful. Frequent spraying with solutions of equal parts of hydrogen diox- 
ide and lime-water will clear away the thick mucus, while the pain is 
relieved by rinsing the mouth with a solution of sodium bicarbonate (a 
teaspoonful to a glassful of water as hot as can be borne). 

Many patients prefer to be their own doctors for a while, and, as a con- 
sequence, by the time they come under observation the process is well 
advanced. For treatment in this and in the later stages nearly every 
drug in the Pharmacopoeia has at some time or other been recommended, 
thus evidencing the fact that there is no specific for the malady. Guaiac 
in the form of troches or the ammoniated tincture in drachm doses in 
milk long enjoyed favor, based, no doubt, on the theory of rheumatic 
causation. In the writer's hands its effects have been very uncertain, 
and it is extremely disagreeable to take in any form. For some years 
he has relied on salol in five-grain doses (adults) hourly, exhibited in 
mucilaginous suspension and flavored with some essential oil, this method 
of taking having proved more reliable than the use of tablets. In a 
series of eighty-one cases it was found that if treatment was begun on 
the first or second day of the disease, pain was, on the average, relieved 
in twelve hours ; if begun on the third day, in fourteen hours ; and if 
begun after the third day, in eighteen hours. The average of all the 
cases was a little over fourteen hours. Allowing for sleep, not more 
than ninety grains are taken in the twenty-four hours, and experience 



DISEASES OF THE UVULA AXD TONSILS. 547 

has shown that in persons with sound kidneys this quantity is perfectly 
safe. In a few cases of the foregoing series a dark color was observed 
in the urine, but nothing more. Other i)rei)arations which may be used 
in place of salol are lactophenin, sodium salicylate, sodium benzoate, 
antij)yrin, acetanilid, and the muriatic tincture of iron ; recourse to the 
latter after failure with some of the newer and much- vaunted remedies 
is often rewarded with success. Estimation of the value of any plan of 
treatment inust recognize the self-limited nature of the affection. During 
the administration of the coal-tar j)roducts the heart must be closely 
watched. Xuclein prepared from the thyroid and thymus glands may 
be given in the same dosage as salol and is warmly recommended by some 
writers. 

Incisions, scarifications, or punctures are not recommended in these 
forms of tonsillitis. If the lacuuai seem small and their mouths are dis- 
tended with inflammatory plugs, it is a good plan to remove the latter 
with a small spoon scoop, and by means of a cotton carrier rub over the 
interior of the lacunj© with guaiacol. This plan is highly extolled by 
Goldstein,^ who has also used for this piu-pose protargol, trichloracetic 
acid, and the Loffler solution (page 694). He advises these applica- 
tions at intervals of eight hours, and he comi)letes the local treatment 
with a gargle of solution of chloride of iron in glycerin. In addition, 
he lays stress on three therapeutic procedures: (1) a saline purge, (2) free 
diaphoresis with j)ilocari)ine and wrapping in blankets, and (3) satura- 
tion of the system by a salicylate or hj sodium benzoate. 

Parenchymatous injections of various remedies have also been sug- 
gested. For this purpose carbolic acid (two or three cubic centimetres 
of a two per cent, solution) has been used, and also solutions of iodine. 
The latter remedy has been apj)lied by cataphoresis. 

Finally, every case of sore throat should be isolated until its exact 
nature is beyond question. 

Acute Croupous Tonsillitis. — By this term is signified an inflam- 
mation with degeneration or death of tissue. The ej)ithelial covering of 
the tonsil may be alone involved, or the change may extend through the 
entire mucosa, with swelling of the surrounding tissues. The exudative 
material is rich in fibrino-plastic substances, and appears on the surface 
of the mucosa, forming a false membrane. 

Etiology. — This form of tonsillitis is often seen as a complication of 
the various exanthemata and infectious maladies, and some cases apiDcar 
in the later stages of kidney disease and of wasting maladies. Croupous 
tonsillitis may also result from many of the causes commonly leading to 
the lacunar form. In one sense it may be said that the special form 
produced by the Loffler bacillus is a croupous tonsillitis, but this has 
reference only to physical appearances. Undoubtedly various micro- 

^ Laryngoscope, 1900, vol. viii. p. 215. 



548 



DISEASES OF THE PHARYNX. 



organisms are capable, under certain conditions, of exciting membrane 
formation, so that there may be an identity of appearance with a bac- 
terial diversity of causation. 

Fathology. — A typical false membrane is present, due to the coagula- 
tion of the exuded liquor sanguinis, rich in fibrino- plastic material, and 
to the emigration of leucocytes. Fibrin ai3pears on the surface, entangling 
in its meshes the leucocytes, now appearing as pus- cells, and subsequent 
coagulation-necrosis leaves superficial erosions or ulcerations of varying 
depth. The staphylococcus and streptococcus are the micro-organisms 
most commonly found. 

Symptoms. — In the main the symptoms are the same as those already 
described, but are more severe. The swelling of the tonsil is not great, 
and the membrane is confined to its convexity ; the glands of the neck are 

swollen and painful, and the prostration is 
^^^- 2^2. under all circumstances well marked. 

Diagnosis. — Dififereutial diagnosis is 
called for, especially from diphtheria. 
Here again it is asserted with much em- 
phasis that the culture alone can decide 
doubtful cases 5 but a common ground 
must be assumed by disputants as to what 
really constitutes diphtheria, and on what 
basis a classification of throat exudates 
is to be made, as in the light of each 
I)ractitioner' s exiDcrience the appearances 
in a given case may incline him to this or 
that view. Valuable evidence is afforded 
by the previous history in regard to ex- 
posure to contagion, but, after all, there 
are many cases which cannot be diagnos- 
ticated from mere inspection. 

Duration and Frognosis. — The disease 
lasts from six to eight days, and the prognosis is almost always good, 
though this statement must be modified in cases in which the tonsillar 
malady is secondary to some constitutional or visceral disease. Patients 
are often left weak from the absorption of septic material. 

Treatment. — The measures given for the milder form of tonsillitis are 
not of much service here, except that hydrogen dioxide spray with lime- 
water may be used. Distinctly antiseptic mouth-washes should regularly 
be applied. Perhaps the best plan is to begin with a bichloride of 
mercury solution (1 to 3000), and when the membrane comes away 
to substitute therefor hydrogen dioxide. Supporting constitutional 
measures should be adopted from the first. Small doses of quinine 
can be taken with benefit, and moderate quantities of alcohol are often 
advisable. 




Acute croupous tonsillitis. (Griinwald.) 



DISEASES OF THE UVULA AND TCXSILS. 



549 



Acute Ulceeatiye Tonsillitis. — Under this title F. J. Moure ^ has 
described a form, of tonsillar disease ^vhieh he regards as a snbvariety 
of ordinary lacunar tonsillitis. It is characterized by the presence on 
the surface of the tonsils of large ulcerated patches which closely re- 
semble specific lesions. Attention had been called by various observers 
in previous years to this class of lesions, but Moure seems to have been 
the first to recognize their true nature. The tonsils present, more fre- 
quently on their mesial aspects, grayish rounded or oval patches covered 
with a cheesy deposit of some thickness, which can, however, easily be 
removed, leaving a mammillated surface. The borders of the ulcer are 
clean cut, but not particularly swollen ; the rest of the organ may be 
somewhat swollen. The ulcerated spots are usually single, without any 
tendency to coalesce, and may occur in succession on the same tonsil. 

Fig. 203. 




Acute ulcerative tonsillitis. (Moure.) 

so that the latter exhibits simultaneously different stages of the lesion. 
The ulcers seem to be of an infective nature, which may explain the suc- 
cessive invasions of the same or of the other tonsil. The x)rocess appears 
to start as an acute inflammation in the crypts. Moure compares the 
gross appearance to that of a cauterized tonsil from which the slough is 
about to separate. 

Etiology. — The condition seems to be more prevalent in the spring and 
fall, and attacks by preference young adults ; no special cause has yet 
been assigned for this x)articular form. The affection has also been styled 
ulcerous chancriform tonsillitis, and more recently has been referred by 
Vincent and others to the siDCcial influence of a spirillum and certain fusi- 
form bacteria, but this point is still undecided. Some have regarded the 
malady as merely a manifestation upon the tonsillar surfaces of the usual 
ulcero-membranous stomatitis which is seen in other parts of the mouth. 



Rev. Internat. de Rhiiiol., 1896, vol. vi. p. 101. 



550 DISEASES OF THE PHARYNX. 

Symptoms. — The symptoms of this form are identical with those of an 
ordinary attack of lacunar tonsillitis. Adenopathy is rarely, if ever, 
observed. 

The particular form of ulcer under discussion does not spread by con- 
tinuity, and remains strictly limited to the tonsils, while the tissue inter- 
vening between the multiple lesions is always unaffected. Moreover, the 
edges of the syphilitic ulcer are surrounded by an angry red zone of pro- 
gressing infiltration, which is entirely wanting in the lacunar ulcer. 

Treatment. — The treatment should consist of a thorough cleansing of 
the surface of the patches with hydrogen dioxide or with the prepara- 
tion known as ^^enzymol," which is a proteolytic ferment of consid- 
erable power, yet without harmful effect upon normal tissues. The 
writer heartily recommends this remedy as being particularly efficient in 
cleansing the surface in various forms of ulceration of the throat, and in 
cases of dead tissue it has seemed far more efficient than hydrogen diox- 
ide. ]^ext, the cleansed area should be thoroughly swabbed with a solu- 
tion of zinc chloride (1 to 30) containing a little cocaine, and the cure is 
completed by the use of a strong gargle of potassium bromide in glycerin 
and water. Initial curetting of the affected area or discission of the ton- 
sil has been recommended. Finally, it seems hardly necessary to say 
that during the active stage all food should be bland and that there 
should be a most careful avoidance of pharyngeal irritants. 

Albuminuric Tonsillitis. — G. F. Keiper^ has reported a case under 
this heading and added some observations on its pathology. His x)atient 
was a man thirty-two years of age, with grave renal trouble. The 
superior portion of the left tonsil showed an ulceration the size of a 
gold dollar, which was covered with an exudate suggestiA^e of diph- 
theria ; this was, however, easily removed without hemorrhage, leaving a 
surface as if scraped out with a sharp spoon. Within three or four 
days severe bleeding took place from the site of ulceration. There were 
several recurrences of the hemorrhage, which finally ceased of its own 
accord, and did not recur -, but death soon followed, owing to the general 
constitutional condition. In such cases there are probably vascular 
changes analogous to those found in albuminuric retinitis, in which the 
walls of the arteries are transformed into homogeneous yellow tubes with 
narrowed lumen. In this condition the blood-stream is retarded and the 
toxic substances in it remain longer in contact with the vessel-walls, and 
hence the latter become diseased by fatty degeneration of the endothelium 
and narrowed by proliferation. "When the laminae become considerably 
reduced or obliterated a dropsical necrosis results, as well as an extrava- 
sation of the constituents of the blood, together with hemorrhages. Cases 
such as that reported by Keiper are infrequent in literature, but if the 
foregoing train of reasoning be correct, it is hard to understand why this 

^ Laryngoscope, 1898, vol. v. p. 275. 



DISEASES OF THE UVULA AND TONSILS. 551 

complicatioD in the throat does not recur more often, considering the 
constant irritation to which the vessels at this point are exposed. 

Gangrenous Tonsillitis. — In the later stages of certain chronic 
visceral diseases there may be an actual gangrene of the tonsil. As 
evidencing low vitality this is an omen of gravest prognostic import ; 
nor is it without local danger, as Cragin ^ has recorded the case of a man 
forty- five years of age whose death was caused by a sudden and copious 
bleeding from the mouth. Autopsy showed a large ulcerated area with 
attached slough occupying the site of the right tonsil and reaching back 
towards the posterior wall of the pharynx. Corresponding to the site of 
the tonsil, two small vessels with open mouths were detected, which were 
evidently the source of the bleeding. 

Xot all cases of gangrenous tonsillitis, however, are fatal. De la Sota ^ 
has seen three recoveries under the use of tonics and local antiseptics. 

Acute Ciecumtonsillae Inflammation (Quinsy). — In this condi- 
tion the focus of inflammation is generally located in the connective 
tissue around the tonsil, especialh^ in front and above. The term ^^sup- 
purative tonsillitis" is objectionable in that it signifies that the abscess is 
in the tonsil itself, which is not often the case. The position of the organ 
with reference to the suj^ratonsillar fossa has already been described, and 
the exact site of the x)us collection has been demonstrated by F. C. Oobb,^ 
who injected a cadaver through the tonsil, using liquid wax, which was 
passed by means of a needle through the superior constrictor muscle into 
the pharyngomaxillary space. The material passed in easily and pro- 
duced on the j)alate the bulging characteristic of quinsy. After the wax 
had hardened, sections of the part were made just below the hard palate, 
showing that the si)ace was filled towards the region of the teeth anteriorly 
and that the wax also extended into the soft palate. Posteriorly the injec- 
tion was stopped by the partition formed by the styloglossus and stylo- 
pharyngeus muscles. Eemoval of the wax left a cavity that would easily 
have accommodated half a fluidounce, and which exteoded not only be- 
neath the tonsil but above into the soft palate. Cobb believes that the 
phenomena of quinsy are easily explained by the accumulation of pus in 
this space. 

It is not asserted that all quinsies have this exact location or that the 
pus always burrows along the lines indicated. Sometimes it oozes from 
the lacunse, and excision of the entire tonsil will show a pus-producing 
cavity at its base ; but even here the discharge seeins to be fed from some 
reservoir behind, for it has been demonstrated that if all the pockets at 
the base of the organ and about the supratonsillar fossa are thoroughly 
opened up and allowed to heal from the bottom, suppuration rarely returns. 



1 New York Med. Jour., September 1, 1888, p. 233. 

2 Cf. Sajous's Annual, 1892, vol. iv. E. 12. 

3 New York Med. Jour., October 14, 1899, p. 571. 



552 



DISEASES OF THE PHARYNX. 



Fig. 204. 



Etiology. — According to Lennox Browne, quinsies form about thirteen 
per cent, of all acute inflammations in tliis region. The general causes 
are the same as those peculiar to the varieties of tonsillitis already de- 
scribed. Any case beginning as a lacunar or parenchymatous form may 
go on to suppuration, and this emphasizes the fact that quinsy is a direct 
infection of the circumtonsillar tissue through the route of a diseased 
tonsil. Most of the cases occur in young adults, though the disease has 
been seen at all ages from seven months to seventy years. ^Neglected 
attacks of acute inflammation seem to predispose to it. 

Bosworth states that he is '' disposed to make the assertion that a sup- 
purative inflammation in the cellular tissue surrounding the faucial ton- 
sil in probably nine cases out of ten should be regarded as a manifestation 
of rheumatism." He further states that '^an acute follicular tonsillitis 

does not and cannot develop a quinsy with- 
out some particular predisposing cause." 

Fatliology. — This affection is a simple 
phlegmonous inflammation in the connec- 
tive tissue surrounding the tonsil, which 
latter may be pushed inward from its bed 
and ai)pear enlarged when it is really not 
so. It shares in the general congestion and 
oedema of the surrounding parts. Occa- 
sionally the suppurative process invades 
the tonsillar substance. The abscess is 
more ax)t to point in the anterior pillar 
at its upjper part or between it and the 
tonsil ; it may, however, point in the pos- 
terior pillar. A possible danger is the 
burrowing of pus downward into the cel- 
lular tissue of the deeper parts of the 
neck, and through it into the mediastinum or the pleural cavities, with 
fatal result. In view of such possibilities it is surprising that some 
authorities still counsel against opening quinsies, preferring to wait for 
spontaneous evacuation. 

Symptoms. — If the suppuration is secondary to a preceding tonsil- 
litis there may be engrafted on the symptoms of the latter an additional 
rigor with high fever and i)rofuse sweating. The whole side of the 
anterior pharynx becomes tense and brawny, while the soft palate is 
pushed forward or may be invaded by the purulent process. A tumor 
can often be felt on the outside of the neck. It is difficult or even im- 
possible for the patient to open the mouth wide enough to introduce a 
tongue depressor, swallowing is agonizingly painful, the uvula may be- 
come cedematous and obstruct free respiration, taste and smell are blunted, 
the voice has a peculiar sound suggestive of the condition, the fauces are 
clogged up with thick, tenacious mucus, and the breath becomes horri- 




Circum tonsillar suppuration, 
wald.) 



(Griin- 



DISEASES OF THE UVULA AXD TOXSILS. 553 

bly offensive. The patient is in a miserable condition, with saliva con- 
stantly dribbling from the mouth, and after a siege of three or four days, 
with its enforced starvation owing to inability to swallow, is often re- 
duced to a condition of very low vitality. 

If left to itself, and if only one tonsil is attacked, the disease generally 
run its course in from one to ten days. If an abscess forms, it will prob- 
ably burst by the end of a week. All cases do not result in actual idus 
formation, the swelling subsiding after a lapse of several days. The in- 
volvement of the second tonsil means, of course, a prolongation of the 
disease. Occasionally a case will continue indefinitelj', the i^rocess neither 
subsiding nor going on to suj^puration. The febrile movement is of vary- 
ing intensity, and its subsidence does not necessarily mean that no i)us 
is present, for there are suppurative cases in which the pus is shut in by 
a wall of inflammator}^ material, so that there is no longer any absorption 
from the abscess- cavity, or, at least, not enough to cause fever. Under 
these circumstances all the constitutional symj^toms may subside while 
the local continue. 

Frognosis. — Eecovery is the general rule, and it is promi^t when once 
the pus is evacuated. A serious though rare comi^lication is oedema of 
the glottis. The abscess may bui^st after swallowing, coughing, or during 
sleep ; in the latter case the pus may be swallowed or may enter the 
trachea, causing suffocation. It is not always easy to find the exact site 
of the exit of pus when spontaneous evacuation has occurred. In ad- 
dition to the invasion of the mediastinum, there may be abscesses in the 
submaxillary glands or lingual muscles ; erosion of the great vessels has 
taken place, and general septicaemia is not unknown. 

Treatment. — At the outset circumtonsillar inflammation calls for the 
same general treatment as the acute forms of tonsillitis. Quinine, 
Dover's powder, aconite, etc., may be given in small and frequent doses 
with the view of aborting the attack. Ice-pellets may be held in the 
mouth and ice ai^i^lied externally. If pus formation seems imminent, 
hot sponges or poultices are jDreferable. Helbing ^ has i)roposed as a re- 
vulsive measure the api^lication of croton oil at the angle of the jaw, and 
hot alkaline washes help to keep the mouth clear of the thick mucus. 
Early incision is advocated, and in the ox^inion of the writer is admissible 
as soon as there is much protrusion of the anterior pillar ; it should be 
followed by a flushing out of the mouth with a hot antiseptic solution. 
Where pus is susi^ected, the blade of the scalpel should be passed in 
horizontally (at least half an inch) through the site of greatest bulging, 
the direction of the incision being from without inward towards the 
median line of the mouth. As the blade is withdrawn it should be 
turned half-way round so as to leave a larger opening and one which the 
parallelism of the muscular fibres will not immediately close up. Cobb 

1 Centralb. f. Lar., 1890, S. 564. 



654 DISEASES OF THE PHARYNX. 

has called attention to the fact that the fibres of the anterior pillar and 
those of the superior constrictor cross one another at an angle, and to this 
is due, he thinks, the occasionally ineffectual results of iDuncture. 

Sometimes the incision is not followed by the immediate escape of 
pus, but the latter may suddenly make its appearance a while after. In 
such a case the point of the knife has probably X3enetrated nearly to the 
purulent focus, and has so weakened the wall of the latter that spon- 
taneous evacuation soon follows. Mere superficial punctures or scari- 
fications are to be avoided, as they do no good and increase the patient' s 
discomfort. If pus does not follow the first incision, a second, or even a 
third, may be made. Incision ' ' acts at once by relieving tension, while 
bloodletting mitigates, and sometimes even cuts short, the disease." The 
gentle and careful syringing of the pus-cavity with a mild antiseptic by 
means of a long curved tube has seemed to hasten convalescence. If 
swallowing is so painful as to interfere with nutrition, the fauces should 
be sprayed with a cocaine solution, after which food may be taken. The 
bowels should be kept open and a supporting regimen followed. Eectal 

Fig. 205. 



Leland's tonsil knife. 

alimentation has at times been necessary, and stimulants may be given 
in moderation. 

A word should be added in reference to after-treatment in cases of 
recurring quinsy. Diseased lacunoe should be opened, the sui3ratonsillar 
fossa freely exi)osed, and, if feasible, a iDortion of the tonsil removed. 
G. A. Leland^ advocates the splitting of the tonsil from top to bottom 
with a sickle-shaped knife and the subsequent insertion of the sterilized 
forefinger, by which means the base of the tonsil is thoroughly explored 
and all x)us-pockets completely destroyed. The advantages claimed for 
this method, which requires slight general ansesthesia, are, first, the pus- 
pocket is definitely located ; second, the abscess is drained from the bot- 
tom ; and, third, recovery is prompt and the process does not recur. 

iN^FLAMMATioiNr OF THE LiNOTJAL ToNSiL. — The lingual or fourth 
tonsil is the collection of lymiohoid tissue on the back of the tongue be- 
tween the circumvallate papillae anteriorly and the anterior surface of 
the epiglottis posteriorly. It is one segment of the " tonsillar ring," and 
presents no peculiarities in either physiology or pathology. Structurally, 



^ Trans. Amer. Laryngol. Assoc, 1899, p. 53. 



DISEASES OF THE UVULA AXD TOXSILS. 555 

its diverticula are single instead of compound, as in the faucial tonsils. 
This lymphoid deiDOsit may scarcely appear above the surface of the 
tongue, or may be In the form of a large central mass or of two masses 
placed one on each side of a median furrow ; it may be so prominent as 
to shut off the view of the glosso-epigiottic fossa. The surface of the 
mass is generally mammillated, and occasionally the epiglottis is fairly 
buried in it, the condition being known as ' ' incarceration of the epi- 
glottis." 

Etiology. — The causes and varieties of acute inflammation of this ton- 
sil are the same as those of the faucial deposits. This localization of 
throat lesion is often overlooked from faulty methods of examination. 
The tongue should be held as in laryngeal examinations (page 592) and 
the large mirror employed, but not i)laced so far back in the mouth as 
is necessary to bring the vocal cords into view. It has been asserted that 
poisonous saliva from dental caries has a specially detrimental effect on 
this ijarticular tonsil. 

Spn2)toms. — The general symptoms are the same as those enumerated 
under the headings of inflammations of the faucial tonsils. The local 
symptoms vary somewhat, due to the different area affected. Thus, the 
feeling as of a foreign body in the throat is especially marked, as is 
also, for obvious reasons, painful swallowing. Pain at the root of the 
tongue is constant, while irritation of the structures at the entrance to 
the larynx causes frequent cough. 

In the lacunar type of attack the constitutional symptoms are apt to 
be more severe than in the corresi)onding inflammation of the faucial 
bodies. The swelling may spread to the epiglottis, and even to the tis- 
sues around the glottic oi^ening, thus causing dyspnoea, at times alarming, 
and possibly requiring operative intervention. The initial pain may be 
referred to the hyoid region, or even over the larynx, so that it is often 
difficult to persuade patients that the latter organ is not the seat of the 
disease. The parenchymatous form is the one most often seen, and calls 
for no special remark. 

The circumtonsillar or sui)j)urative variety (lingual quinsy) is less 
common than the faucial, owing to the relatively scanty amount of con- 
nective tissue at the base of the tongue. The special demand in these 
cases is to determine the exact site and nature of the inflammation with 
which the practitioner has to deal, and both the finger and mirror should 
be used as guides to diagnosis. It is well to remember that these attacks 
are sometimes ushered in by an oedema of the glottis. Spontaneous 
evacuation of the abscess during sleep, especially if it be posterior, in- 
troduces an element of great danger. Cases of chronic abscess of this 
region and of retention cysts are on record. 

Treatment. — The treatment of these various forms of lingual tonsillitis 
is identical with that of corresponding lesions of the faucial structures. 
As local applications tannin and morphine msij be used, care being taken 



556 



DISEASES OF THE PHARYNX. 



Fig. 206. 



not to exceed a tlierai)eiitic internal dose of tlie latter, glycerite of boro- 
glycerin, weak solutions of cocaine or eucaine, menthol (fifteen grains) in 
olive oil (one ounce), etc. During the acute stage the inhalation of the 
vapor of boiling water poured on hops is gratefully borne, and convales- 
cence may be hastened by swabbing the area with a solution of per chlo- 
ride of iron in water, one part to eight. Most of these cases are not of a 
serious nature, but one must be prepared to act promptly, as some of 
them are so severe as to suggest that condition known as '^Ludwig^s 
angina." The similarity of the symptoms to those of retropharyngeal 
abscess is apparent, but palpation will readily determine between the two. 
Enlarged Lingual Veins — Lingual Yarix. — Enlarged veins are 
frequently seen coursing over the region of the lingual tonsil, and give 

rise to a well-defined train of symp- 
toms. In addition they may be tortu- 
ous and irregularly dilated, giving a 
varicose appearance. The title ' ' hem- 
orrhoids of the tongue" has also been 
applied. 

Etiology. — The condition is more lia- 
ble to occur in neuropathic patients and 
in those suffering from any chronic vis- 
ceral disease which prevents venous re- 
turn. Torpid livers, chronic digestive 
disorders, rectal hemorrhoids, and lin- 
gual varix often go together. Lennox 
Browne, who has described the affection 
in great detail, has seen two cases in 
association with diabetes, and it seems 
occasionally to be one of the local mani- 
festations of a general tendency to vaso- 
motor neuroses. It is rare before the 
twentieth year and very common about 
middle life. The majority of the cases seen by the writer have been 
women at the menopause. 

Pathology. — The veins appear as a net-work of dark reddish or reddish- 
blue streaks or bands, with here and there local enlargements or nodosi- 
ties, small ampullae in which the blood stagnates ; the deeper veins may 
be in a similar condition, while the lingual tonsil itself may or may not 
be enlarged (Fig. 206). 

Symptoms. — These are much the same as those of simple enlargement 
of the tonsil, with the important addition that the vessels may from time 
to time rupture, thus giving rise to small hemorrhages which greatly 
alarm the patient, as he is ai^t to refer them to tubercular trouble in the 
lung. Browne has seen two cases of torticollis, in one of which removal 
of enlarged lingual veins relieved the muscular spasm. 




Lingual varix. (After Lewin.) 
nous trunks ; 6, terminal plexus ; 
cumvallate papillae. 



a, ve- 
c, cir- 



DISEASES OF THE UVULA AND TOXSILS. 557 

Treatment. — The diet should be regulated and the bowels kept opeu. 
If the tonsil is large, it should be removed by methods to be mentioned 
later, while if the veins alone are dilated, they can be destroyed by the 
galvano- cautery at a dull-red heat. The patient should be cautioned to 
avoid for a while all hot ingesta and irritants. Sips of ice-water afford 
much relief to the after-smarting, which, however, is not excessive or of 
long duration, and various sedative troches may also be used. 

CHEOXIC IXFLAMMATIOXS OF THE TOXSILS. 

Under this heading are included the same varieties of chronic as of 
acute tonsillar inflammations. The chronic catarrhal variety is really 
one feature of a chronic i)haryngitis and calls for no special remark. 

Cheoxic Lacuxae Toxsillitis.— This form may succeed a series of 
acute attacks or may be i^resent without antecedent history. The tonsils 
may or may not be enlarged. From time to time the crypts become filled 
with cheesy masses ; inflammatory bridles of low-grade connective tissue 
occlude the lacunar orifices, and thus lead to accumulation of cheesy 
material. Sokolowski thinks that there may be a villous ingrowth of 
epithelium into the lacunae, each minute villus containing a lym^^h -follicle. 
Eetention of contents leads successively to irritation, dilatation, and in- 
flammation. These plugs, which emit a very ofiensive odor, are of a 
yellowish- white color, and composed of epithelial debris, leucocytes, fatty 
granules, cholesterin, mineral salts, and various bacterial and mycotic 
elements. The lacunae at the to^) and bottom of the tonsil are most com- 
monly affected, and pressure on some other part of the organ will often 
express their contents. This is the '• caseous tonsillitis'' of some writers. 
It is at once evident that the condition interferes with the proper func- 
tion of the tonsils and the outi^ouring of the normal lymphatic stream. 
IN'aturally, the movements of surrounding structures in deglutition tend 
to keep the lacuna free. 

Symptoms. — Minor degrees of this condition are very common, and 
small deposits do not necessarily cause any symptoms whatever. If they 
are large, if many lacunae are affected, and the process one of long 
duration, there is more or less faucial irritability with actual pain, 
possibly radiating to other parts of the throat, or even to the ears, and 
increased on swallowing. The breath is fetid and the tongue frequently 
coated. Swallowing of saliva is often more painful than swallowing of 
food, and morning cough is frequently present. Excessive use of the voice 
or excess in tobacco increases the discomfort. From time to time the 
patient may expel the plugs, whereupon relief follows until their reac- 
cumulation. The mental condition of these patients is sometimes deplor- 
able, as they imagine that they are affected with a grave and incurable 
malady. 

Diagnosis. — Inspection as ordinarily made will be without result. 
The faucial pillars must be carefully separated from the tonsils, the probe 



558 DISEASES OF THE PHARYNX. 

used, and all the crypts thoroughly explored. Three definite sites must 
be carefully scrutinized : (1) the upper part of the tonsil between the 
pillars (supratonsillar fossa) ; (2) the bottom of the tonsil just where the 
lymphoid deposit is stretching out to join a corresponding extension 
from the lingual tonsil ; and (3) the middle of the tonsil (Gumpert) im- 
mediately behind the anterior pillar^ or the area which so often becomes 
covered with the plica tonsillaris. The condition is frequently over- 
looked and the dysaesthesia variously referred to lingual veins, enlarged 
pharyngeal follicles, hysteria, etc. ; meanwhile the patient gets no better, 
and may begin to complain of pains in the neck and chest and of various 
neuralgias. Should the disease continue, acute inflammation may super- 
vene. There are here ideal conditions for bacterial growth, and after 
exposure to cold or the ingestion of hot or irritating foods the impris- 
oned bacteria may take on increased virulence with the usual result of 
an acute outbreak. 

Treatment — After locating the seat of the disease with a ptobe, each 
lacuna should be cleaned out by some spud-like insti^ument or scoop 
and the inflammatory bridles thoroughly slit up with some form of 
hooked knife. The bared areas should then be carefully curetted and 
rubbed with a cotton carrier dipi)ed in a solution of iodine and x^otas- 
sium iodide, one drachm of each to an ounce of water. If the mouths 
of the lacunae are relatively high up on the surface of the tonsil while 
their cavities extend downward, a cautery tip bent to fit each indi- 
vidual area should be passed to the bottom of the recess and the current 
allowed to burn its way out. This treatment will generally effect a per- 
manent cure. Large tonsils should be removed en masse. 

Chronic Parenchymatous Tonsillitis. — By this term is meant the 
familiar condition known as "enlarged tonsils." It may be the legacy of 
preceding acute attacks, or may occur so early in life that it is impossible 
to say just when it began. It is a striking expression of the tendency to 
lymphatism seen in young children, especially those of a strumous diath- 
esis or who are exposed to bad general hygiene, being em^Dhatically a 
tenement-house disease. It is seen, however, in adults and in those com- 
fortably housed and fed. 

Fathology. — One or both tonsils may be enlarged and of varying con- 
sistency, according to the relative amounts of lymphoid and connective- 
tissue elements. In the child, and in recent cases in young adults, the 
organ feels soft and pulpy, while in cases of longer duration it is hard 
and fibrous. Tonsils may be enlarged from vascular conditions or from 
inflammatory oedema, but here there is a true hyperplasia, or increase in 
the number of lymphoid elements. On inspection of the excised organ, 
the connective- tissue element is frequently visible to the naked eye, ap- 
pearing in the form of trabeculse running through the mass, which by 
their contraction become more or less lobulated. These connective-tissue 
trabeculse bear directly upon the question of hemorrhage after removal 



DISEASES OF THE UVULA AXD TONSILS. 



559 



Fig. 207. 



of the tonsils. In the soft organs the vessels retract after section of 
the tissue, and their mouths quickly become plugged with coagula as 
under ordinarj' circumstances ; but where the connective-tissue element 
becomes excessive their mouths are held open after section, and the 
vessels, as a whole, do not retract within their sheaths, but become 
canalized. It is true that the organ may feel soft at its surface, but it 
may be quite hard at the plane of section, and its general state invites 
frequent exacerbations of acute inflammation. The combination with 
the enlargement of diseased lacunje leads, as explained in the preceding 
section, to a clogging up of the lacunae and the accumulation of various 
waste products behind these obstacles. Eemoval of a section of surface 
tissue corresponding 
to the depth of these 
lacunae will often give 
temjDorary relief, but 
such a i)rocedure is 
mentioned only to be 
condemned. It is fal- 
lacious in its results, 
for it is not suf- 
ficiently thorough, 
and the continuance 
of the conditions 
which caused the 
original lesion will 
lead to its recur- 
rence. 

As previously 
mentioned, the an- 
terior faucial pillar 
often appears as a 
broad and thick mem- 
brane which projects 

partially over the anterior half of the tonsil, and by a x^rocess, apparently 
of contraction, has pressed and partially rotated the organ backward on 
its vertical axis, so that whatever j)ortion of its free surface remains un- 
covered presents towards the posterior pharyngeal wall. This band is 
sometimes the j)illar itself, but at others a structure quite distinct there- 
from, and the two should be separated before removal of the tonsil is at- 
tempted. The posterior pillar may also be firmly adherent, though no 
fibrous band develops in this situation. 

Symptoms. — Enlarged tonsils are in a sense foreign bodies ; they ac- 
cordingly^ give rise to physical symptoms, but as they represent the out- 
come of perverted phj'siological processes, they present in addition symp- 
toms referable to the systemic condition. Physically, all functions of the 




Hypertrophy of the faucial tonsil. (Seifert and Kahn.) 



560 DISEASES OF THE PHARYNX. 

surrounding parts are more or less liindered. An enlarged pharyngeal 
tonsil (so-called adenoids) frequently coexists, and it may be difficult to 
determine to which of the two diseased areas a given symptom is due ; 
but as both areas are essentially a continuation of one and the same struc- 
ture, this point is of minor importance. Certain it is, however, that 
the removal of enlarged tonsils, by allowing perfect postnasal drainage, 
will often afford relief to many of the symptoms attributed to postnasal 
disease. The voice is thick and muffled, the patient often si)eaking as if 
the mouth were full, some of the normal resonance of phonation is lacking, 
and breathing is somewhat interfered with. In the adult dyspnoea is rare. 
In children the oropharynx is encroached upon to such an extent that 
the function of the nasopharynx is also interfered with, and a slow car- 
bonsemia occurs. Snoring and mouth-breathing may be present, and the 
need of oxygen frequently becomes so great that the child will wake up 
suddenly, j)resenting the familiar picture of night-terrors. The senses 
of hearing, smell, and taste are all blunted ; the enlarged tonsils also 
directly interfere with the free action of the delicate muscles which 
govern the functions of the Eustachian tubes. 

While in adults enlarged tonsils may cause only discomfort and im- 
pairment of special sense, the case is quite different in growing children, 
who are apt to suffer from defects in general physique and especially in 
chest development. After operation they will sometimes improve as if 
by magic. Doubtless many chest deformities supposed to be due to en- 
larged tonsils should be ascribed along with the latter to some underlying 
dyscrasia, both being effects of one common cause. 

In addition to the foregoing symptoms, it may be added that the 
breath is offensive, the stomach disturbed, and the bowels out of order -, 
nocturnal enuresis is also often present. The inspired air passing over 
surfaces which contain decaying materials in their crypts offers to the 
child a vitiated atmosphere. 

Diagnosis. — While a casual inspection reveals the enlarged tonsils, the 
act of gagging brings them even more prominently into view. 

Treatment. — The first thing to be decided is the exact character of the 
enlargement, and this can to a certain extent be predicted from the age 
of the patient and his previous history as regards tonsillar attacks. 
Under such circumstances the operator naturally looks for a more or less 
fibrous tonsil, one which is liable to bleed. The tonsil of the recent case, 
or of the young child, will be soft, evidencing the preponderance of the 
lymphoid element over the fibrous. In any event, the region should be 
carefully palpated before operative intervention, though even then one 
cannot predict the amount of connective tissue which may exist at the 
exact plane of section. 

No reliance can be placed on the probability of spontaneous atrophy, 
though some surprising cases of this happy result are on record. It is 
true that the tonsils atrophy in later life, but this process is a prolonged 



DISEASES OF THE UVULA AND TOXSILS. 561 

one, aud mean while permanent damage may be done to the ears and the 
foundation laid for permanent catarrhal troubles which, by proper opera- 
tion at the right time, might have been entirely avoided. 

Singers often ask as to the effect of tonsillotomy on the singing voice. 
Such x^ersons should be shown their entire misconception of the relation 
of these lymphoid deposits to the system in general. Large tonsils in- 
terfere with the free action of the faucial muscles, occasion vocal fatigue, 
and invite fresh attacks of inflammation ; hence their removal is followed 
by advantages along these three lines. It is true that there are cases on 
record in which removal has occasioned the loss of one or two of the 
highest notes of the scale, but the patients have admitted that this loss 
was more than compensated by the imi)rovement in the quality of the 
voice and by lessened fatigue. 

Medical treatment should not be overlooked, as it is an important 
factor in the cure. In young patients a course of iron following opera- 
tion seems distinctly beneficial ; either the muriated tincture or some 
combination with manganese may be emj)loyed. Local applications to 
the tonsils are a waste of time so far as reduction of size is concerned, 
though they may lessen the frequency of recurrent inflammation. They 
are feebly palliative, but in no wise curative. 

Eemoval having been decided on, the next step is the selection of a 
method. If this is to be done en masse, either cutting, snaring, or burn- 
ing instruments may be used. A question much discussed recently is 
whether or not tonsillotomy is justifiable in conditions of acute inflam- 
mation. It is suggested by the fact that there are cases in which the 
tonsils are, when inflamed, quite large, but when the acute stage has 
passed they shrink so much that it is impossible to engage them in any 
cutting or snaring instrument. B. Friinkel ^ believes that tonsillotomy is 
often demanded in the acute stage, his experience in acute lacunar con- 
ditions being that the ]3atients do just as well as under ordinary circum- 
stances. In this connection the rules given by Lennox Browne are worthy 
of quotation in full. '' (1) Kever inflict unnecessary pain by useless scari- 
fications on the surface of a tonsil undergoing general inflammation. (2) 
Never make deep incisions unless there is an almost absolute certainty of 
advanced suppuration. (3) Eemove, on the subsidence of acute attacks, 
tonsils enlarged and liable to quinsj'. (4) Eemove the tonsils as soon as 
they become sufficiently^ enlarged in those cases of recurrent quinsy in 
which there is not chronic enlargement, but in which the tonsil, though 
diseased, is too small for excision except on occurrence of acute inflam- 
mation. By this means the existent attack is at once cut short and the 
chance of further attack avoided." 

The first step in a proposed tonsillotomy is to find out whether or 
not the tonsil is adherent to the faucial pillars. If it is, this adherence 

1 Arch. f. LaryngoL, Bd. iv. S. 132. 
36 



562 



DISEASES OF THE PHARYNX. 



must be severed by means of various knives provided for the purpose 
some of which are here figured. ^ 

Yery useful instruments also for this purpose are the right and left 
scissors used by gynaecologists for operations on the perineum, though 



i 



Fig. 208. 



^^■■ffliiil^^ 



^ amtii^^^^^^^s^ 




Set of tonsil instruments (Makuen's), consisting of two knives (right and left), one probe, and one 

curette. 

for the present purpose the handles may advantageously be shortened. 
After the tonsil is thus freed, it will be found to project much farther 
into the oral cavity, a position which permits of its more complete re- 
moval. Mackenzie's and Mathieu's guillotines are now usually employed. 

Fig. 209. 




Mackenzie's tonsillotome. 



One objection to the old model of the Mathieu instrument is its com- 
plicated construction, which makes it difficult to take apart and keep 
clean. Ermold, of :N'ew York, has, however, modified the instrument so 
that it now consists of only three pieces and one small screw, and can 
instantly be taken apart and kept clean without the least difficulty. 



DISEASES OF THE UVULA AND TONSILS. 



563 



As will be noted by reference to the figure, its fenestra is oval in the 
vertical direction, while that of the Mackenzie instrument is round. 
Lennox Browne prefers the Mackenzie model with the fenestra oval in 
the horizontal direction and with an angular instead of a rounded cutting 
edge. The patient should be seated in a high-backed chair, behind which 
stands an assistant. The use of a mouth-gag is optional. The assist- 

FiG. 210. 




Mathieu's tonsillotome (Ermold model). 

ant, firmly holding the i)atient's head, presses the tonsil in towards the 
median line of the mouth. The guillotine is then passed over the mass 
to be removed, pressed firmly against the side of the pharynx so as to 
make the tonsil project as much as possible through the fenestra, and 
the section is made. The employment of an anaesthetic in these cases is 
a matter of choice. If adenoids are to be removed at the same time, its 
use is most certainly advised, and the ideal agent is nitrous oxide gas, 

Fig. 21 L 




ErmoWs tonsillotome. 

the administration of which will provide an anaesthesia lasting fully long 
enough for the removal of tonsils. If longer unconsciousness is desired 
it may be followed by a little ether. Chloroform is preferred by some, 
but if the double oi3eration is to be performed it is not considered by the 
writer to be free from danger. 

As concerns the use of cocaine in these cases of tonsillotomy, it must 
be remembered that the degree of anaesthesia by local a]3plication is very 



564 DISEASES OF THE PHARYNX. 

slight. A Yulsellum forceps can be used to lift the tonsil from its bed 
before section is made. Under these circumstances the patient can hold 
the tongue- depressor himself. 

Ethyl bromide has been recommended as an anaesthetic in these oper- 
ations. It has had an extended use on the Continent, but has not come 
into general employment in this country. The patient can be seated in 
a chair or, if a child, held in the lap of an assistant. The anaesthetic 
(from one-half to three-quarters of a fluidounce) is freely poured on 
an Esmarch inhaler and applied closely to the face. Anaesthesia is ob- 
tained in from thirty seconds to two minutes. The cornea becomes insen- 
sible, the eyes are generally open with some dilatation of the pupils, 
the face is congested, and the muscles are at first somewhat relaxed. 

IN'o positive rule can be given as to the age at which the liability 
to hemorrhage (see below) renders some method of removal other than 
by cutting advisable. Generally speaking, other methods are preferable 
after the patient has passed the twentieth year. 

In case general anaesthesia is employed, the patient may lie on the 
side, with the head turned towards a strong light and on a plane slightly 
lower than that of the body. Under these circumstances the blood will 
readily run out from the corner of the mouth and may be caught in a 
basin. In any event, whether general anaesthesia is or is not employed, 
the patient should keep perfectly quiet for the next twenty-four hours, 
and children must, without exception, be kept in bed. All hot ingesta 
should be avoided, conversation prohibited, and all foods taken be soft 
and pultaceous. Crackers and dry toast should especially be forbidden. 
The patient should gently rinse the mouth every hour or two with a cold 
antiseptic solution, and ice-pellets may be freely used. Inspection will 
often show within a day or two a thin white pellicle over the cut surface ; 
this may be regarded as an expression of a mild infection from the bac- 
terial flora of the mouth, probably from the streptococci, which are 
always present. Mild febrile symptoms may ensue, but they are tempo- 
rary and rarely require treatment. The exudate consists almost entirely 
of fibrin, leucocytes, and necrosed tissue of the surface of the wound 
(Harmer). 

A. A. Bliss ^ has called attention to certain conditions of the tonsils 
which limit the usefulness of the tonsillotome. He notes that many of 
the patients presenting themselves for treatment do not show the typical 
form of tonsils as laid down in the text-books, and consequently that 
there are many in whom the use of the tonsillotome is impracticable. 
For the irregularly shaped and hard nodular though small tonsils he 
prefers, in place of this instrument, one which permits of a dissection of 
the parts to be excised from the surrounding tissues, a method of pre- 
cision which does not leave the amount of tissue . to be removed to the 

1 Jour. Am. Med. Assoc, March 12, 1898, p. 591. 



DISEASES OF THE UVULA AXD TOXSILS. 565 

chance of engagement or non-engagement of the ring-knife. He finds 
the ideal instruments in a pair of crocodile-jaw forceps and scissors, the 
special features of the latter being long, powerful handles, relatively 
short, stout blades, and a socket into which the shank of the lower blade 
falls as the scissors close. This socket arrangement x>resses the blades 
together and i)revents their springing apart when thickened tissue is 
severed. In proportion to the whole number of tonsillotomies, fatal bleed- 
ing must be rare. Under ordinary circumstances the gush of blood fol- 
lowing section is considerable but temporary, ceasing in the course of a 
minute or two. Frequently the primary hemorrhage is trifling, while 
some hours or even days after a secondary bleeding may occur, which 
gives rise to the greatest anxiety, and the number in whom the bleeding 
has continued up to the point of fainting is considerable. This stage is, 
however, generally attended by such a lowering of the blood- pressure 
that the bleeding ceases, not to return. 

Conditions favoring hemorrhage are haemophilia, hardness of the ton- 
sils leading to a canalization of the vessels after section, wounding of the 
anterior pillars, and an abnormal distribution of blood-vessels. It has 
been asserted that the submucous injection of cocaine, used as a local 
anaesthetic, may be responsible for some cases. The use of sui)rarenal 
extract for the exsanguinatiou of the part is too recent to afford definite 
data. It should be remembered in this connection that while cocaine 
causes anaemia of a part by direct influence on the vasomotor aj^paratus, 
that of suprarenal extract is exerted upon the muscles in the walls of the 
blood-vessels. It will be seen that there are many cases in which the 
occurrence of hemorrhage cannot possibly be foreseen ; the conditions 
favoring it may all apparently be wanting in a given case, and yet bleed- 
ing will follow. 

A fatal result in a non-haemophilic child is practically unheard of, — 
that is, where the faucial tonsils alone (and not the pharyngeal tonsil) 
have been removed. The vast majority of the cases have occurred in 
adults. The deduction from the statements just made is that no one 
should attempt the removal of the tonsil without being prepared for 
hemorrhage, for it may occur at any time ; and, though the operator 
may be comforted by the thought that fatalities are very rare, he ought 
not to subject his patients to the debilitating effects which follow a 
severe loss of blood, and, moreover, he should have very clear ideas as 
to the course to be followed in case this complication arises. As Daly 
has said, any one who uses the guillotine on tonsils without reference to 
the condition of the organ and other attendant circumstances will some 
day meet his Waterloo. Once again special stress should be laid upon 
the routine after-treatment with reference to the character of the food 
and to abstinence from physical exertion. The practitioner who gives 
careful directions in these respects and insists upon literal obedience 
thereto will be far less liable to meet with accidents than the one who 



566 DISEASES OF THE PHARYNX. 

dismisses his patient with a general exhortation to be carefnl what he eats 
and to keep quiet. If, however, bleeding does ensue, the tonsil should 
be most carefully examined and, if possible, the bleeding-point located. 
Bosworth finds the most common site of a spurting vessel at the junction 
of the lower third with the upper two-thirds of the cut surface. Torsion 
should first be used according to surgical rules, and if this fails, or if the 
bleeding occurs as an oozing from an extensive area, either pressure or 
cauterization may be exerted. Pressure may be applied by the thumb 
over the bleeding area and counter-pressure with the middle finger of the 
same hand on the outside of the neck at a point corresponding to the site 
of the tonsil. This measure will certainly check the bleeding, but the 
objection to it is that it requires to be kept up several hours in extreme 
cases and may provoke considerable retching on the part of the sufferer. 
If, however, it can be continued for a fairly long time, the clots forming 
in the mouths of the vessels will become sufficiently organized to remain 
in place after the pressure is removed. The use of the finger may be 
replaced by special instruments constructed on the general principle of 
substituting pads for the fingers, controlled by suitable spring pressure. 
The same likelihood of gagging, however, is seen here as with the fingers. 
As a type of instrument of this kind may be mentioned that of Butts 
(Fig. 212). 

Fig. 212. 




Butts's tonsillar hsemostat. 

Eegarding the use of the cautery, it may be said that the skill of 
modern instrument- makers has led to the employment of either the 
gal vano -cautery or the Paquelin instrument. The former has the dis- 
advantage of being small, so that its heat is rapidly dissipated when 
applied to a bleeding surface of any considerable size. Where it is aj^pli- 
cable, torsion is better. The Paquelin instrument, however, is so con- 
structed that its heat can be maintained at any desired point. It should 
be heated up to a dull cherry- red. If this fails, the final resort is liga- 
tion of the carotid vessels, first the external, then, if necessary, the com- 
mon, and finally the internal, but such extreme measures are rarely neces- 
sary. It may suffice to keep the mouth full of ice-pellets, or to use the 



DISEASES OF THE UVULA AND TONSILS. 567 

familiar combinatiou of Morell Mackenzie (gallic acid, one part ; tannic 
acid, three parts ; water, four parts ^, which, should be sipped slowlj^ in 
full strength, and not used as a gargle. Chemical caustics do not find 
here a proper field of application. Especially should such i)reparations 
as Monsel's solution of iron be avoided. They are all uncertain, inef- 
ficient, and so obscure the field of operation by the formation of a pasty 
clot that subsequent manipulations are all the more difficult. 

The possibility of bleeding from the use of cutting instruments has 
led to the substitution of various other means of section. One of these 
is the cold-wire snare. For this i)urpose may be used a snare constructed 
on the same general model as that employed for the removal of nasal 
polyps. It must be much stronger, however ; in fact, large and strong 
enough to carry a No. 10 steel piano-wire. The instrument known as 
Far low's meets all the requirements. Under its use the bleeding is usually 
of a trifling character, as the wire can be tightened so slowly that the 
vessels are occluded. The operation is extremely painful, and generally 
requires (always in children) the use of an anaesthetic. It has the advan- 
tage of allowing the careful adjustment of the wire, and if the i^illars are 

Fig. 213. 



^■'"'waii 




Farlow's tonsil snare, 

separated so that the looj) of the wire sinks deeply around the base of the 
tonsil, it is j)ossible literally to remove the entire organ with its capsule. 

The application of electricity in various forms may next be considered. 
It is, however, j)ractically limited to the electro -cautery point or snare. 
The ease with which this agent may be controlled, the accuracy with which 
it may be applied, and the thoroughness of its effects have led to its re- 
placing all of the old chemical cauterizing agents, such as chromic acid, 
silver nitrate, and the well-known London paste. The objection to all 
these and similar remedies is that they are relatively sujperficial in their 
action, so that many aj)plications are required. 

Concerning the application of the cautery point (the method of igni- 
puncture), it may be said that it is an ideal method for those cases in which 
the size of the tonsil is not great, where a cutting operation is objected 
to, and where there is a relation of the tonsillar tissue to surrounding 
structures which prevents the removal of the tonsil en masse. The 
operation is not especially painful, though many sensitive patients greatly 
complain of the smell of burning flesh, which they declare is far worse 



568 



DISEASES OF THE PHARYNX. 



than the pain. The latter can practically be iDrevented by injecting into 
the spots selected for the application of the cautery a drop or two of a 
two per cent, solution of cocaine, carrying it under the mucosa by means 
of a curved needle, and cauterizing quickly after. The cautery should 
be applied cold to the area which is to be burned, and then heated 
and allowed to burn its way out. Care should be taken not to have it 
too hot. It should be tested with the rheostat before insertion, allowance 
being made for the fact that the moisture of the part operated upon will 
abstract some of the heat. 

A heat approaching the white should be the standard used, for when the 
hot cautery comes in contact with the moist tissue it will be cooled down to 
the proper temperature. Too great a heat will lead to possible hemorrhage, 
though, under the circumstances, this is trifling. Again, caution should 
be exercised with reference to bearing outward with the electrode when 

Fig. 214. 




Schech's universal handle for galvano-caustic operations in the pharynx, nose, and larynx. 
a, snare ; b, cautery for the turbinates ; c, d, e, cauteries for granulations and hypertrophied lateral 
bands ; /, cautery for the turbinates. Any of these tips may be used for tonsil operations, according to 
the requirements of each individual case. 



the heat is turned on, so as to leave a perfect drain and to prevent im- 
paction of a slough in the cicatrix, as it may lead to local supi^uration. 
Several sites may be cauterized at one sitting. When the surface of the 
tonsil is smooth and there seem to be no special points for insertion of the 
cautery-tip, broad furrows may be burned across it, say two each way. 
Patients should be advised of the necessity of eating only bland foods and 
avoiding hot ingesta for a few days after treatment. A slough will appear, 
which will clear off in from four to six days, at which time the burning 
can be repeated on the other tonsil. 

A valuable method is that of the electro -cautery snare. For this 
purpose the Schech handle (Fig. 214) will answer, as it has the necessary 
devices for tightening the wire and interrupting the current. Gradle 
has devised a snare in which the ordinary steel piano- wire can be used. 



DISEASES OF THE UVULA AXD TOXSILS. 



569 



Ordinarily, platinum wire may be employed, with which iridium can be 
advantageously combined, as the latter element adds firmness to the loop, 
so that it can more easily be j)laced around the tonsil. After the organ 
is engaged, the current is turned on for two or three seconds, and the 
wire allowed to sink its way into the tonsillar tissue ; a circular furrow 
is thus burned around the base of the organ. The snare is further tight- 
ened, and the current again turned on. By a succession of these move- 
ments the furrow gradually deepens and the tonsil is finally severed. A 
slough is left, covering the 

entire surface of the tonsil, Fig. 215. 

but this will come awaj" in 
a few days. This method 
has the advantage of being 
bloodless. Care should be 
taken to avoid wounding 
the faucial pillars. Cocaine 
should be freely applied to 
reduce the local irritability 
of the throat, for unless this 
is done it is extremely dif- 
ficult to properly adjust the 
loop. After-treatment is the 
same as above described. 

J. Wright has adapted 
the current to the mechanical construction of the Mackenzie tonsillotome, 
so that the cutting edge of the latter is replaced by a stiff wire, which 
can be driven against the tonsil and made to burn its way through. The 
instrument is somewhat large, however, and it requires considerable for- 
titude on the part of the patient to keep it in the mouth long enough for 
the removal of any considerable portion of tonsillar tissue. An objection 
to both of the last-named methods is that the patient can rarely keep 




^Y^ight■s electric amygdalotome. 



Fig. 216. 




Knight's electric tonsil snare. 



from gagging more or less, a procedure which is apt to result in burning 
the tongue or the anterior pillars. To prevent this, C. H. Knight has 
devised an instrument (Fig. 216) in which "the double canula carrying 
the wire (No. 30 platinum) is attached to a solid steel shaft, from which 
it is thoroughly insulated. The shaft ends in an ovoid ring, to corre- 
spend with the shape of most tonsils. The ring may be of different 



570 DISEASES OF THE PHARYNX. 

sizes. The loop is sliaped to adapt itself to the ring, to which it is fas- 
tened by a single thread at its distal extremity. The tonsil having been 
surrounded by the ring, traction is made on the loop, bringing it in con- 
tact with the tonsil above and below. At this instant the current is 
turned on, the thread holding the wire is burned through, the wire buries 
itself, and the further steps of the operation are simple. . . . The instru- 
ment should, of course, always be so applied as to carrj^ the ring first 
over the base of the tonsil, the wire loop lying on its inner surface. . . . 
This method has two advantages. In the first place, there is no difficulty 
in putting the wire around the tonsil, and in the second place, the velum 
and the dorsum of the tongue are guarded by the steel ring, which 
remains perfectly cool." 

Chroxic Encysted Abscess of the Tonsils. — This condition is 
responsible for certain cases of swelling in the tonsillar region. It may 
follow an acute suppuration, from the persistence of a cavity lined with 
a pyogenic membrane. If the cavity has an outlet through some of the 
lacunae, the pus drains away as soon as it is formed, but if there is no 
such drainage, it may accumulate without acute symptoms or give rise 
to a repetition of the acute features. There seem, liowever, to be some 
abscesses which are chronic from the beginning. They are analogous in 
their mode of formation to the ordinary cold abscess, though they do not 
present any tubercular element. The encysted j)us seems to be of a very 
low grade of virulence, and this is doubtless one factor in the chronicity 
of the condition. Most of the patients in reported cases have been young 
male adults. The x) us- cavities are generally deep in the tonsillar tissue. 
The contents may be ordinary pus, but are more often of a grumous con- 
sistency, sometimes syrupy, or, if the condition is one of long standing, 
fatty, like the contents of a sebaceous cyst. The individual pus-cells are 
fatty and granular, and contain cholesterin crystals. The cavity-wall is 
of a low grade of connective tissue, organized at the expense of the sur- 
rounding tonsillar parenchyma. Bacteriologically, the sac contents are 
like those of abscesses in general. In one of Peyrissac's cases the staph- 
ylococcus albus was isolated. 

Symxytoms. — The symptoms are j)ractically those of simple hypertrophy. 
There are no acute manifestations, but an intermittent purulent discharge 
may suggest the cause of the tonsillar prominence. Eecent cases may 
give a feeling of fluctuation, while those of long standing are hard, even 
like fibromata. The exploring needle may be used in cases of doubt. 

Treatment. — If possible, the whole tonsil should be excised with the 
guillotine or gal vano- cautery snare. The abscess- cavity is thus laid bare, 
and its walls should be thoroughly curetted. A solution of zinc chloride, 
forty grains to the ounce, to which a little cocaine has been added, is 
then well rubbed over the curetted surface. 

Chronic Enlargement of the Lingual Tonsil. — The nature of 
this condition has been sufficiently outlined in preceding pages. It 



DISEASES OF THE UVULA AND TONSILS. 



571 



may occur in connection witli enlargement of the faucial structures, or 
exist alone. It is more common at tlie middle period of life, a time when 
the other tonsillar dei)osits have gener- 
ally atrophied. In the experience of the 
writer, it is more common in women. 
The symi)toms are the same as those of 
the acute variety, except in degree. 



Fig. 217. 






l\: 



^ 



r 



^x: 



rr- 



There are the constant feeling as of a for- 
eign body, various pharyngeal dyssesthe- 
siae, spasm of the oesophagus, sometimes 
globus hystericus, and frequeutly an 
impairment of vocal clearness and en- 
durance. Perhaps the most common 
symptom of all is an annoying, dry, 
irritating cough, which is often worse at 
night. Examination of the chest fails 
to reveal any abnormality of the lungs, 
and the cause of the cough is not determined until the region of the lingual 

tonsil is examined. 

Fin. 218. 



Hypertrophy oi tlie lingual tousil. 
(McBride.) 




Hypertrophy of the lingual tonsil. 



(Seifert and Kahn.) 



Treatment consists in the removal of the offending tissue. A wire 
snare in a cui'ved canula, the wire being either hot or cold, may be used 



572 



DISEASES OF THE PHARYNX. 



to remove the offending masses, or they may be taken off with a lingual 
tonsillotome (Fig. 219). 

In case the masses are not large enough to engage in any of the fore- 
going instruments, the ignipunCture method may be used (page 567). 




219. 



Myles's lingual tonsillotome. 



Care must be taken not to burn too freely in this locality, for the pro- 
duction of too much scar tissue may predispose to later neoplastic 
formation. 

Polypoid Hypertrophy of the Tonsils. — Apart from hyper- 
trophy of the tonsil as a whole, sometimes there is found a local enlarge- 
ment, giving rise in a lesser degree to the same symptoms as general 

hyx^ertrophy, and remediable by the 
same measures, especially the galvano- 
cautery snare, as the growths are more 
or less pedunculated. In these ad- 
junct masses there is generally an ex- 
cessive development of connective tis- 
sue, which at times resembles an actual 
sclerosis. Such growths may be acces- 
sory tonsils, or may present as an elon- 
gation at the site of attachment of one 
or several lobules of a multilobular 
and hypertrophied tonsil. Occasion- 
ally the entire tonsil is pedunculated. 
A marked example of this condition is 
that reported by Lemariey^ (Fig. 220). 
In his case the length of the pedi- 
cle was sufficient to give rise to 
symptoms of suffocation. In some 
of the reported cases evidences of a 
tubercular tendency were noted, but these were doubtless accidental. 
Some of the masses may have been pure fibromata. Lemariey's case 
presented as its characteristic histological features submucous plaques of 
fibrous tissue, and, entirely apart from these, perivascular deposits of the 
same nature. According to Hajek, some of the masses take their origin 




Polypoid hypertrophy of the tonsil. (Lemariey 



^ Ann. des Mai. de 1' Oreille, 1895, vol. xxi. p. 452. 



DISEASES OF THE UVULA AND TONSILS. 573 

from the strangulation of a x^ortion of adenoid tissue, while others are an 
elongation of the point of insertion of an accessory tonsil. There would 
appear to be no reason why, at any point in the ring of Waldeyer, the 
lymphoid elements should not take on an abnormally large development, 
and if such excess of growth is at a point where the action of muscular 
structures would tend to stretch it, the mode of polyp formation is easily 
understood. 

Foreign Bodies in the Tonsils. — Under this heading are included 
parasites, calculi, and deposits of bone or cartilage. Foreign bodies are 
mostly sharj) or slender substances, such as fish-bones, pins, and bristles 
from tooth-brushes. Morell Mackenzie has called attention to the fact 
that some patients are especially liable to this accident, which may come 
from improper mastication of food, irregularities of structure, or defective 
sensibility of the mucosa. The symx^toms are a x^ricking and stinging 
pain, aggravated on movement. Mere inspection may fail to locate the 
body, but careful palx)ation will generally determine its exact x^osition. 
At times the body may migrate through the tonsillar tissue, and so for a 
time escape detection. Incision into the tonsil may be necessary here, 
but when once the body is found its extraction with forcex^s of various 
kinds is an easy matter. 

Tonsillar Calculi. — These may occur in any part of the tonsils 
or in the faucial pillars. Goodale ^ has rex^orted a unique case of cal- 
culus occurring in the uvula of a colored child two months old. The 
mass caused symptoms of sufifocation, but was easily enucleated with cut- 
ting forceps. Several years ago C. A. Parker' removed a calculus from 
the right side of the palate. The site looked like an ulcerated surface, 
while the surrounding tissues were hard and inflamed. Calculi in this 
general region x^robably originate in the accumulation of cheesy matter 
in the cryx3ts of the mucosa. Most of this accumulation is squeezed out 
by the movements of the jaw in mastication. If for any reason a x:)ortion 
becomes imx^acted in a cryx^t, it may become the seat of calcareous de- 
posits. The nucleus is ax3t to be a foreign body, especially the lex^to- 
thrix, which seems to predispose to cheesy deposits. These irritating 
masses often set ux3 inflammation. 

The symx^toms of these calculi are those of a foreign body, while the 
hardness may be suggestive of a malignant growth. Exx^loration with a 
needle will reveal the nature of the mass. Treatment consists in an in- 
cision over the most x^rominent x^art, turning the calculus out of its bed, 
and thoroughly cauterizing the latter. In one instance, quoted by Bos- 
worth, Anselmier, finding calcareous matter in a palatal recess, passed 
into the latter a tampon saturated with a weak solution of sulx^huric acid, 
and dissolved out the offending material. 

^ Boston iSIed. and Surg. Jour. , December 8, 1898. 
^ Trans. London Path, Soc, December 15, 1893. 



574 DISEASES OF THE PHARYNX. 

Bony and Cartilaginous Growths in the Tonsils. — Several in- 
stances of this condition liave been reported during the last few years. 
Hugh Walsam ^ has found small masses of cartilage occurring as trabeculsSj 
rings, or nodules. He is convinced of the close analogy between these 
masses and those small cartilaginous deposits which develop in the course 
of the branchial clefts in the neighborhood of the ear or sometimes lower 
down in the neck. He thinks that they are derived from the second 
branchial arch, and are, therefore, to be looked on as foetal remnants. 
For reasons unknown, in after-life these nodules may take on growth and 
proliferation. Distinctly bony trabeculae have been found mainly in per- 
sons well advanced in years. Under such conditions they might be con- 
sidered as senile changes ; but bone has also been found at as early an age 
as two years, and it is therefore probable that there are from the first 
potential centres of ossification. Kanthack dissents from the view above 
expressed as to origin, and believes the nodules to be not the result of 
embryonic inclusion, but merely a metaplasia of fibrous tissue into bone 
or cartilage. 

Stirling ^ has approached the subject from a somewhat different point 
of view in his report of three cases. His first case was that of a girl, who 
complained of pain in the right tonsil radiating to the right nasal bone, 
mastoid, eye, and shoulder. Caseous masses had been i)ressed from the 
tonsil, and the force required in doing this had caused intense pain. 
Palpation showed a hard mass extending from behind and underneath 
the tonsil to the level of its anterior surface ; the mass appeared rounded 
and pointed. In front the finger could be laid in the angle between the 
mass and the maxilla, while behind it there was another angle between the 
tumor and the right side of the vertebral column. The tonsil itself was 
somewhat enlarged. 

Wingrave^ has seen several specimens of cartilaginous deposits in 
tonsils generally the seat of chronic hypertrophy. Sometimes they have 
been located in a fibrous bed and sometimes in the lymphoid pulp, but 
never in the lymph-follicles or nodules. Calcareous deposits were found, 
but never osseous. This author thinks that as '' vestigial rests" they may 
possibly be the foci of neoplastic formations and deserve closer study 
than has thus far been given them. He adds the practical observation 
that their occurrence may explain the feeling of resistance occasionally 
noticed in section of the tonsil with the guillotine. 

Xerostomia (Dry Mouth). — This is a rare condition of the mouth, 
in which the tongue is red, cracked, and dry ; the buccal surface of the 
cheeks and the hard and soft i^alates are also dry, and the mucosa becomes 
pale, smooth, and glistening. Speech is difficult, as is also swallowing. 



^ London Lancet, August 13, 1898, p, 534. 
2 Jour. Am. Med. Assoc, 1896, p. 743. 
' London Lancet, 1898, vol. ii. p. 750. 



DISEASES OF THE UVULA AND TONSILS. 0/0 

There appears to be no constant pathological condition of the salivary 
glands. The disease usually occurs after middle life, and, outside of the 
two cases reported in men by Seifert, is seen in women. 

Of the cases reported, three had a sudden beginning, two of them 
having had a severe mental shock 5 another case occurred in an hysterical 
woman who had anuria, while a fifth patient was very hypochondriacal. 
The tongue is often cracked, like alligator skin. On its anterior x)art 
]3apill8e are often wanting, but the circum vallate papillae are preserved. 
Common sensation is unimpaired, but, owing to the dryness, that of taste 
is weakened or entirely lost ; at the same time, dryness of the nasal and 
lachrymal apparatus may be noticed. The disease usually reaches its 
maximum intensity in a short time, and may then remain stationary for 
years. In some instances dryness of the skin and falling out of the teeth 
have been observed. Urinary examination has shown nothing. In some 
cases the parotid glands are enlarged. 

No satisfactory explanation has yet been found for this curious con- 
dition. The symptoms suggest a trophoneurosis, — some affection of a 
nervous centre (still hyj)othetical) controlling the secretion of all the 
buccal and salivary glands. Only about twenty cases have been recorded. 

Treatment. — Pilocarpine and the potassium salts have been given with 
the idea of increasing secretion, but without definite effect. Glycerin 
applications have afforded some relief to the uncomfoitable dryness of 
the mouth. 



DISEASES OF THE LARYNX. 



CHAPTEE XL 

ANATOMY AND PHYSIOLOGY OF THE LARYNX. 

The larynx may be considered as a cartilaginons box with incomplete 
sides opening above into the iDharynx and below into the trachea. Placed 
at the upper and fore part of the neck, it forms a considerable prominence, 
known as the pomum Adami or Adam's apple, more prominent in men 
than in women. It lies between the large cervical vessels, and below the 
level of the tongue and the hyoid bone. Its anterior boundaries are along 
the middle line, skin, and cervical fascia ; on each side are the sterno- 
thyroid and thyrohyoid muscles, the upper end of the lateral lobe of the 
thyroid gland, and a small portion of the inferior constrictor muscle 
of the pharynx. Posteriorly, the prgevertebral muscles and the laryngo- 
pharynx intervene between it and the fourth, fifth, and sixth cervical ver- 
tebrae. 

From the measurement of a small number of cases Sappey gives its 
dimensions as follows : height, from the upi)er border of the thyroid car- 
tilage to the lower border of the cricoid, forty- four millimetres in men 
and thirty-six millimetres in women ; breadth, or distance between the 
posterior borders of the thyroid cartilage, forty-three millimetres in men 
and forty-one millimetres in women ; antero-posterior distance from the 
most prominent point of the anterior thyroid border to a line uniting its 
posterior borders, thirty-six millimetres in men and twenty-six millime- 
tres in women. 

The component parts of the cartilaginous box present various articu- 
lations and are united by elastic membranes or by ligaments. The ten- 
sion of the latter is modified by the action of various muscles, which 
also move the cartilages on one another. The mucous lining of the box 
is continuous above with that of the pharynx and below with that of the 
trachea. 

Cartilages. — The cartilages may be divided into two groups, — those 
occurring singly and those occurring in j)airs. Of the single cartilages, 
the largest and most prominent is the thyroid (shield), which consists of 
two flat plates united in front at an angle of about ninety degrees, like 
the letter Y. At the top this junction is prominent and subcutaneous, 
forming the Adam's apple. The x)lates are approximately quadrilateral. 
The anterior border is the shortest, forming with its fellow the deep thy- 
roid notch. The posterior border is thickened and vertical, being pro- 
576 



AIs-ATOMY AND PHYSIOLOGY OF THE LAEYXX. 577 

longed above and below into x)rocesses called cornua, or horns. Attached 
to it are the stylopharYngeus and palatoiDharyngens mnscles. The ui^per 
and lower borders have each a deej) concavity- close to the cornna ; other- 
wise, the top border is convex and the bottom nearly straight. The 
external surface of each plate, or ala, is flattened, and has near the pos- 
terior part of the upper border a sux3erior and at the lower border an 
inferior tubercle. Between these two passes an oblique ridge separating 
the anterior three-fourths of the surface from the posterior fourth. This 
ridge gives attachment to the thyrohyoid muscle, and below to the sterno- 
thyroid ; the smooth surface behind it, to a part of the inferior constrictor 
of the pharynx. 

On their internal surfaces the oliB are slightly concave and x)erfectly 
smooth. The superior cornua i)ass ui>^'ard and slightlj' backward and 
inward, each terminating in a blunt extremity, which is attached by 
means of the lateral thyrohyoid ligament to the greater cornu of the 
hyoid bone. The inferior cornua are directed slightly forward, and show 
on the inner aspect of their tij)S a blunt facet, for articulation with the 
cricoid cartilage. Quain calls attention to the fact that occasionstlly an 
abnormal branch of the superior laryngeal artery penetrates the thyroid 
ala near the ui)j)er part of its posterior border. 

The cricoid cartilage (signet-ring) is deep behind, where it presents a 
quadrilateral surface, with a vertical measurement of about one inch, but 
in front its vertical measurement is only about one-quarter as great. 
A cross-section is circular at the lower border, but elliptical higher w]). 
The inferior border is flat, resting on the trachea, to which it is united by 
membrane. The superior border, markedly elevated behind, tapers off 
rapidly towards the front, presenting a deej) concavity below the thyroid 
cartilage. The posterior upper border has a median depression, with 
lateral facets for articulation with the arytenoid cartilages ; these facets 
face outward and upward, and are slightly convex. In front and at 
the sides the external surface of the cartilage is smooth, giving attach- 
ment to the cricothyroid muscle. In the middle of the i)OSterior surface 
is a ridge, to which are attached some of the muscular fibres of the 
cesoi^hagus. Lateral to this ridge, on either side, is a broad hollow for the 
posterior crico-arytenoid muscle. Outside the attachment of the latter is 
the articulation with the inferior cornu of the thyroid cartilage. The in- 
ternal surface is smooth, being lined by the laryngeal mucosa. 

The epiglottis is a yellow cartilaginous lamina, obovate in shape, cov- 
ered by mucosa, lying in front of the upper laryngeal opening, and usually 
projecting uj)ward behind the base of the tongue. Broad and rounder at 
its ux)]pei' free margin, it is i)ointed and tongue-like below, and by means 
of the thja^o-epigiottic ligament is attached to the re-entrant angle of the 
thyroid alse a little below the median notch. Its lateral convex borders 
are enveloped below in the folds of the aryteno-ei3iglottidean folds of 
mucosa. Anteriorly, its surface is free above, but below the mucosa is 



578 



DISEASES OF THE LARYNX. 



reflected forward to the tongue, forming the median and lateral giosso- 
epiglottic folds. Below, a median elastic fold (hyo-epiglottic ligament) 
connects it with the posterior surface of the hyoid bone. The posterior 
surface is entirely free, concavo-convex from above downward, but con- 
cave from side to side. The convexity fits down, so to speak, into the 
entrance of the laryngeal cavitj', and is spoken of as the cushion or 
tubercle of the epiglottis. The cartilage is covered with mucosa, the 



Fig. 221. 




Front view of the larynx, thyroid cartilage in 
position. (Browne.) 1, 2, superior cornua of 
thyroid ; 3, 4, inferior cornua of thyroid ; 5, hy- 
oid bone ; 6, 7, cornua of hyoid hone ; 8, 9, thyro- 
hyoid ligament ; 10, 11, epiglottis ; 12, 13, alse of 
thyroid cartilage ; 14, cricoid cartilage ; 15, cri- 
coid membrane ; 16, trachea. 




Side view of the larynx. (Browne. ) 1, promi- 
nence of thjToid cartilage {povium Adami) ; 2, cri- 
coid cartilage ; 3, 4, upper border of cricoid car- 
tilage ; 5, 6, lower border of cricoid cartilage ; 7, 
thyroid cartilage ; 8, 9, superior cornua of thyroid 
cartilage ; 10, right inferior cornu of thyroid car- 
tilage ; 11, articulation of thyroid cartilage with 
cricoid cartilage ; 12, cricothyroid aperture ; 13, 
epiglottis ; 14, trachea. 



removal of which shows minute depressions, lodging the mucous glands 
opening on the surface. 

Of the paired cartilages, the most prominent are the arytenoid (shaped 
like the lips of a pitcher), symmetrical in form and position. They are 
irregular, triangular pyramids, resting by their bases on the upper poste- 
rior part of the cricoid, while their apices, somewhat incurvated, approxi- 
mate. They are about one-quarter of an inch wide and half an inch 
high. The posterior surface is broad and triangular, concave from above 
downward, lodging a portion of the arytenoideus muscle. The anterior 
(external) surface presents a transverse ridge at the junction of its mid- 



AXATOMY AXD PHYSIOLOGY OF THE LAEYXX. 



579 



die and lo^er thirds. Above and below this are concavities. Xear 
the inner end of the ridge is inserted the false vocal band, and at its 
outer portion and in the adjacent hollows is attached the thjro-ary- 
tenoidens muscle. The narrow internal surface, parallel with that of 
the opposite cartilage, is covered with mucosa. The anterior and poste- 
rior borders of this latter surface are nearly vertical, while the external 
border separating the anterior from the posterior surface is oblique. 
The base of each arytenoid is concave, having towards its outer 
part a facet for articulation with the cricoid cartilage, on which it 
rests. 

It remains to speak of the angles. The external is short and rounded, 



Fig. 223. 



Fig. 224. 





The cricoid cartilage, the arytenoid cartilages, 
and the cartilages of Santorini. (H.Allen.) The 
structures last named have been called comicula 
laryngis. a, comicula laryngis ; 6, vocal process ; 
c, attachment of crico-arytenoid, posticus and 
lateralis ; d, arytenoid. 



Side view of the larynx, sho-wing the interior, 
the right plate of the thyroid cartilage being re- 
moved. (Browne.) 1, 2, arytenoid cartilages ; 3, 
3, vocal processes of the arytenoids ; 4, muscular 
process of the right arytenoid ; 5, upper border of 
cricoid cartilage ; 6, 3, 3, vocal bands ; 7, facet for 
articulation with the lesser horn of the thyroid 
cartilage ; 8, left plate of thjToid ; 9, left superior 
horn of the thyroid cartilage ; 10, cricoid carti- 
lage ; 11, trachea. 



extending backward and outward 
from the plane of the base, and 
giving insertion to the lateral and 
posterior crico-arytenoid muscles, 
hence called the muscular i)ro- 
cess. The anterior vocal process, 
pointed in a horizontal position, 
gives attachment to the true vocal 



cord. 

Surmounting the curved apices of the arytenoids are the cartilages 
of Santorini, or cornicula laryngis, two small yellowish nodules, conical 
in shax)e, articulating with the summits of the arytenoids and prolonging 
them backward and inward. 

The cartilages of Wrisberg, or the cuneiform cartilages, are situated 
one on each side in the fold of mucosa which reaches from the summits 
of the arytenoids to the epiglottis. They are small, yellowish, conical in 



580 DISEASES OF THE LARYXX. 

shape, with the base directed upward, and appear in the laryngeal image 
simply as elevations of the mucosa. 

The cricoid and thyroid, with the bottom part of the arytenoid, are 
composed of ordinary hyaline cartilage, and in later years ossify more or 
less, while the epiglottis, thecornicula, and the cuneiform cartilages are com- 
posed of yellow fibrous or elastic cartilage, and show no tendency to ossify. 

Marked changes occur in the larynx at the age of puberty. In the 
later months of foetal life the organ is fully the width of two vertebrie 
higher than in the adult. Descent begins just before birth, and the adult 
position is reached at puberty. Up to the latter period no change is dis- 
cernible between the male and female organs, but at this time the female 
larynx increases in size, and this is the only notable alteration. The male 
larynx, however, not only increases in size, but becomes as a whole more 
prominent and visible at the upf)er part of the neck. All the cartilages 
become stronger, the angle of junction of the thyroid alee n^ore promi- 
nent, and the notch between them deepened. The effect of this is to 
lengthen the distance between their inner angle and the arytenoids, with 
a consequent lengthening of the vocal cords. Ossification begins in the 
cartilages about the twentieth year. 

From a developmental point of view, the thyroid represents the ven- 
tral remains of the skeletons of the fourth and fifth pairs of visceral 
arches, united by a median plate, represented in turn by the union of the 
alse. The cornua, or processes, of each ala represent the ununited parts 
of the two arches. The develoiDment of the other cartilages is variously 
described. According to E. Dubois,^ the epiglottis represents a chondri- 
fication in the submucosa of the glossolaryngeal fold. In a similar man- 
ner the cartilages of Wrisberg are formed in the false cords. Gegen- 
bauer ^ holds that the epiglottis is an index)endent element of the body 
derived from the sixth pair of visceral arches, while, according to Gop- 
pert,^ the cartilages of Wrisberg are formed from the lateral processes of 
the primitive epiglottis. 

Ligaments. — The next point to be considered is that of the membranous 
and ligamentous attachments of the various parts of the larynx. Above, 
the organ is connected with the hyoid bone by the thyrohyoid membrane, 
or middle ligament (Figs. 225 and 226), which is attached below to the 
entire upper border of the thyroid, and inserted above at the posterior 
and upper margin of the inferior surface of the hyoid, which is obliquely 
inclined. In consequence of this the larynx will slip, when drawn up in 
the act of swallowing, within the ring of the hyoid bone. In the median 
line the membrane is quite thick, but on each side, where it is covered b}^ 
the thyrohyoid muscles, it thins out, and is perforated by the superior 



^ Anatom. Anzeiger, 1886. 

2 Kolliker's Festschrift, 1892. 

3 Morph. Jahrb., 1894, Bd. xxvi. 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 



581 



laryngeal artery and nerve. At the posterior border on each side of the 
membrane a lateral thyrohyoid ligament (distinctly elastic) passes from 
the upper cornu of the thyroid to the extremities of the greater cornu of 
the hyoid. 

The connection between the thyroid and cricoid is partly membranous 
and i3artly articular. The median portion of the cricothyroid membrane, 
broader below than above, is a yellowish, elastic ligament, uniting the 
adjoining borders of the two cartilages. In front, it is nearly covered in 
by the cricothyroid muscles, while across it runs an anastomotic twig 



Fig. 226. 



Fig. 225. 



d—l 




The hyoid. bone and larynx, with ligaments, 
seen from in front. (H. Allen.) a, lesser horn; 
b, fat beneath hyothyroid membrane ; c, great 
horn ; d, lateral thyrohyoid ligament ; e, crico- 
thyroid (deep portion) ; /, cricothyroid (superfi- 
cial portion) ; g, cricothyroid membrane. 




The same, seen from the side. (H. Allen.) a, 
capsular ligament. 



between the cricothyroid branches 
of the superior thyroid arteries. 
The lateral portions of the mem- 
brane become much thinner above, where they are continuous with the 
inferior thyro-arytenoid ligaments. 

Between each inferior cornu of the thyroid and adjoining side of the 
cricoid is a distinct joint with a capsular ligament lined with synovial 
membrane. The axis of this joint passes transversely, so that the move- 
ment is practically one" of pure rotation, though there may be a slight 
gliding forward and backward. 

Of the thyro-arj^tenoid ligaments there are two pairs, — superior and 
inferior. The former, consisting of a few delicate fibrous strands in the 



582 



DISEASES OF THE LARYNX. 



folds of mucosa, are known as the false vocal cords, or ventricular bands. 
They are attached in front to the angle between the al£e, just above its 
middle, and close to the attachment of the epiglottis : behind, to the inner 
part of the ridges on the anterior surface of the arytenoids. The inferior 
pair are attached in front similarly to the superior, but lower down. 
Posteriorly, they are inserted into the anterior projection of the base of 
the arytenoid cartilage. Their sharply defined inner edges, covered by 
mucous membrane, form on each side the true vocal cords, but in other 
directions the limits of the ligaments are less sharply defined. Above, 
the fibres of each ligament lie near the upper surface of the projecting 
fold of mucous membrane bounding the rima glottidis, becoming merged 
into the elastic tissue of that membrane. Below, there is a gradual union 
with the lateral cricothyroid ligament, of which the ligament may be 
described as an upward extension. 

The crico-arytenoid articulations have a ligamentous Ci^psule, with 
synovial membrane. The facets of the arytenoids are concave and those 
of the cricoid convex. The movement at this joint is a double one : 

first, a rotation around the nearly perpendicu- 
■^^^- ^^''- lar axis, and, second, a lateral gliding in and 

out, the arytenoid leaving or approaching its 
fellow. There may be a combination of the 
two movements, a point to be well considered 
- . in attempting to account for some of the pecu- 
liar positions of the cartilages seen in laryngeal 
The rima glottidis, a. (H. Allen.) paralyses. It should be remembered that under 

normal conditions, when the larynx is at rest, 
the arytenoid rests on the outer part of the articular surface of the 
cricoid. 

Internally, the larynx is divided by the rima glottidis into an upper 
and lower chamber (Figs. 228 and 229). The margins of the anterior 
two-thirds of the rima are formed by the edges of the true vocal cords. 
The upper chamber is sometimes called the '^ vestibule," communicating 
with the pharynx above. Immediately above the rima lie the ventricles, 
and still higher, the false vocal cords. Below the rima the lining of the 
larynx is continuous with that of 'the trachea, without any sharj) line of 
demarcation between the two. 

The upper aperture of the larynx is, when open, wide in front and 
narrow behind, being triangular. The anterior and iDOsterior boundaries 
are respectively the epiglottis and the summits of the arytenoid carti- 
lages. At the sides are the aryteno-epiglottidean folds, passing from the 
tips of the arytenoids to the sides of the epiglottis. In these folds are 
the Wrisberg cartilages and a few fibres. The mucosa covering the true 
cords is thin, which causes them to appear yellowish or, more often, 
pearly gray or pink. 

The rima is divided into an anterior, or vocal, and a posterior, or 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 



583 



respiratory, portion. In easy respiration, when it is moderately open, it 
has the shape of a triangle, with its base posteriorly ; in a condition of 
full dilatation it becomes lozenge-shaped. The rima measures in men 
about twenty-three millimetres in length and from six to eight milli- 
metres across in its widest part, which can be dilated to nearly double 
that distance ; in women the measurements are about one-third less. 
The length of the vocal cords themselves is about fifteen millimetres in 
men and eleven millimetres in women. 

The ventricles, or sinuses of the larynx, are situated between the false 



Fig. 228. 




Side view of tii^ ...i;. ..x, ^ilo\vi^g the left 
-ventricle of Morgagni, left epiglottic ligament, 
etc. (Browne.) 1, 2, left vocal band ; 3, elevation 
indicating the site of the left cartilage of Santo- 
xini ; 4, 5, left ventricular band, false vocal band ; 

5, 4, 2, 1, entrance to left ventricle of Morgagni ; 

6, elevation indicating the site of the left cartilage 
of Wrisberg ; 7, aryteno-epiglottidean (arj^epiglot- 
tic) ligament ; 8, arytenoid muscle. 



Fig. 229. 




View of the larjTix; opened from behind. 
(Browne.) 1, 2, cricoid cartilage ; 3, 4, arytenoid 
muscle ; 5, 6, vocal bands ; 5, 7, 6, 8, entrance 
to the ventricles of Morgagni ; 7, 8, ventricular 
bands, superior thyro-arytenoid ligaments ; 9, 10, 
cartilages o.f Santorini ; 11, 12, cartilages of Wris- 
berg ; 11, 12, 13, 14, aryteno-epiglottidean (ary- 
epiglottic) ligaments ; 15, epiglottis ; 16, trachea ; 
17, cushion of epiglottis ; 18, 19, cuneiform car- 
tilages. 



and true cords. From their anterior part there is an upward prolonga- 
tion known as the sacculus laryngis, or pouch of the larynx. It runs 
up for about half an inch between the false cord and the thyroid car- 
tilage, being covered on its outer surface by the fibres of the thyro-ary- 
tenoid muscle. Each pouch is abundantly supplied with glands and 
nerve-twigs from the superior laryngeal. The arrangement of the mus- 



584 



DISEASES OF THE LARYNX. 



cular fibres about the poucli is such that their contraction easily serves to 
empty it. 

The laryngeal mucosa is, as a rule, thin and closely attached to the 
neighboring parts. About the aryteno-epiglottidean folds it has much 
subjacent loose areolar tissue, conducive to copious inflammatory exuda- 
tion. As a rule, the mucosa is ciliated, though on the true cords them- 
selves it is of the stratified variety. The same condition obtains from 
a level slightly above the false cords at the sides and the middle of 
the epiglottis in front. 

The arteries (Figs. 230 and 231) 



Fig. 230. 




come from the superior thyroid 
branch of the external carotid 
and the inferior thyroid from 
the subclavian. The veins join 
the superior, middle, and inferior 
thyroid groups. There are upper 
and lower lymphatics, the former 
piercing the thyrohyoid mem- 
brane and the latter the crico- 
thyroid. The former lead to 
glands near the carotid bifurca- 
tion. 

The nerve-supply (Fig. 232) 
is from the pneumogastric, by 
means of the superior laryngeal, 
to the entire mucosa, the crico- 
thyroid muscle, and, in part, the 



arytenoid muscle. 



bearing 



thus 



infill 

Arterial supply of the larynx, posterior view, 
showing the distribution of the superior laryngeal 
artery. (Bosworth.) 



in its trunk both motor and sen- 
sory fibres. The inferior laryn- 
geal nerve supplies all the mus- 
cles except those named above, 
and in part the arytenoid. 

Muscles of the Larynx. — The 
muscular supply of the larynx 
may be studied from various 
stand-points. As some of the muscles have more than a single function, 
it is hard to divide them into groups. Attention is therefore called to 
them in order, the function or functions of each being stated. 

Two muscles not strictly belonging to the larynx may be mentioned 
here, as, by their action on the organ as a whole, they j)lay an important 
part in voice-formation. These are the sternothyroid and thyrohyoid. 
The sternothyroid arises from the upper thoracic surface of the sternum, 
and is inserted into the oblique line on the ala of the thyroid cartilage. 
The thyrohyoid is practically an upward continuation of the former, 
arising from the oblique line on the ala of the thyroid and being in- 



ANATOMY AXD PHYSIOLOGY OF THE LARYXX. 



585 



serted iuto the lower border of the body and greater cornu of the hyoid 
bone near their junction. The contraction of the former tends to lift 
and that of the latter to depress the cartilaginous box of the larynx. 
The resulting combined action firmly fixes the larynx against structures 
behind, so as to allow of a more perfect action of the muscles which 
do not connect with external parts. Other muscles also contribute, 
though to a less degree, to this steadying action. 

Of the intrinsic muscles, there is first the cricothyroid (Fig. 233) or, 
better, on the i^rinciple of using 
in a combined name the first 
part to indicate the fixed and the 
second to indicate the movable 
portion of the structures acted 
on, the thyrocricoid. It is at- 
tached above to the inferior bor- 
der of the thyroid cartilage and 
to the anterior border of its infe- 
rior cornu. Below, it is attached 
to the cricoid cartilage from the 
median line, a considerable way 
back, its fibres passing upward 
and outward, slightly diverging. 
The thyroid cartilage being fixed 
by the action of the extrinsic 
muscles just described, the action 
of the thyrocricoid will be to 
draw the cricoid cartilage uj) and 
back, thus rendering the vocal 
cords tense. 

The posterior crico-arytenoid 
muscle arises from the broad de- 
pression on each side of the me- 
dian line of the posterior surface of the arytenoid cartilage, and its con- 
verging fibres i^ass upward and outward, being inserted into the outer 
angle of the base of the arj'tenoid cartilage behind the attachment of the 
lateral muscle of the same (Fig. 234). The outer or more horizontal 
fibres of the former tend to draw each cartilage from its fellow, while 
the inner or lower fibres rotate it on its base, the outer angles of the 
cartilages being rotated backward and outward, thus throwing directlj^ 
outward the anterior or vocal processes to which are attached the vocal 
cords. The rima giottidis is thus widened. 

The lateral crico-arytenoid runs along the upi)er sloping border of the 
cricoid cartilage, the origin extending along this border as far back as the 
articular surface for the arytenoid. It is thus concealed in great measure 
by the ala of the thyroid. Its fibres pass up and back to be inserted into 




Arterial supply of the larynx, anterior view, show- 
ing the distribution of the inferior laryngeal artery. 
(Bos worth.) 



586 



DISEASES OF THE LAEYXX. 



the muscular process of tlie arytenoid. This action of this muscle is to 
rotate the arytenoid cartilage so as to bring its vocal process towards the 
median line, thus narrowing the rima giottidis. 

It should be borne in mind that the movement of the cricoid on the 



Fig. 232. 



Fig. 233. 




Course of the laryngeal branches of the vagus nerve 
in the new-born. (Henle.) 1, mastoid process ; 2, jugular 
vein, severed ; 3, plexus gangliformis ; 4, internal branch 
of the accessory nerve ; 5, pharyngeal branches of the 
vagus uniting with the pharyngeal branch of the glosso- 
pharyngeal nerve ; 6, superior laryngeal nerve ; 7, in- 
ternal branch of the superior laryngeal nerve ; 8, external 
branch of the superior laryngeal nerve ; 9, left vagus 
nerve ; 10, thyrohyoid rauscle ; 11, cardiac branch of the 
left vagus nerve ; 12, right vagus nerve ; 13, cardiac 
branch of the right vagus nerve ; 14, right recurrent 
nerve ; 15, left recurrent nerve ; 16, ductus arteriosus 
Botallo. 



is a seesaw one, the arytenoids rocking 
sected larynx dispenses with the action 
owing to the complicated structure and 





iiiiiiJiU'i 



Side view of the larynx, showing right 
cricothyroid muscle. (Browne.) 1, 2, 3, 
cricothyroid muscle ; 4, right inferior cornu 
of thyroid ; 5, thyroid cartilage ; 6, 7, su- 
perior cornua of thyroid ; 8, epiglottis ; 9, 
trachea. 



arytenoid is not one of mere 
rotation. Bonnier^ has care- 
fully studied this matter, say- 
ing that physical experiments 
upon a dissected larynx can 
never imitate the normal ac- 
tion of phonation. The ary- 
tenoids, he says, do not pivot 
on the cricoid around a verti- 
cal axis. The true movement 
outward and inward. A dis- 
of the extrinsic muscles, and, 
musculature of the larynx, any 



^ Arch. Internat. de LaryngoL, 1898, vol. xi. p. 339. 



ANATOMY AND PHYSIOLOGY OF THE LARYNX. 



587 



physiological movement is a resultant of complicated muscular action, for 
the various parts to which the muscles are attached are always playing on 
one another. In order to maintain the mutual relation of the cricoid and 
thyroid during phonation, the thyroid is raised by the elevators of the 
larynx to prevent tilting. By this is meant the changing of the relative 
position of anterior and posterior insertions of the vocal cords. 

If the patient sighs, — that is, closes the glottis without phonation, — 
this movement of rocking can easily be appreciated. The typical picture 
observed in phonation is that of adduction of the vocal cords to a position 




Muscles of the larynx, seen from behind. 
{Browne.) 1, 2, cricoid cartilage ; 3, 4, arytenoid 
muscle ; 5, 6. thyroid cartilage ; 7, 8, hyoid bone ; 
9, 12, cartilages of Santorini ; 10, 13, cartilages of 
Wrisberg ; 11, 14, 15, epiglottis ; 16, trachea ; 17, 
thicker (cushion) portion of the epiglottis ; 18, 19, 
posterior crico-arytenoid muscles ; 20, 21, 22, 23, 
arytenoid. 




Side view of the larynx, showing interior of 
the left half. (Browne.) 1, 2, 3, 4, left vocal band 
and thjTO-arytenoid muscle ; 5, left arytenoid 
cartilage ; 6, 7, cricoid cartilage ; 5, 7, lateral crico- 
arvtenoid muscle. 



nearly that of effort, but not quite, however, for there is no actual contact 
of either true or false cords. The latter leave the former visible between 
them, and the former are sufficiently apart to reveal the existence of a 
glottic aperture. The more acute and intense the sound the greater is 
the closure of the interarytenoid portion of the rima glottidis. 

The tlujro-arytenoid muscle consists of two portions, one lying just 
within the ala of the thyroid and the other, more internal, in contact 
with the vocal cord. Attachment in front is in the receding angle of the 
thyroid. The internal portion is attached to the whole length of the 
vocal cord, being inserted behind in the vocal process of the arytenoid, 



588 DISEASES OF THE LARYNX. 

while the external, spreading out more widely, is inserted in the anterior 
surface of the arytenoid. The external portion relaxes the cords, while 
the internal portion approximates their edges in the production of some 
of the finer notes. The complicated action of this muscle arises from 
the fact that many of its fibres do not extend through its whole length, 
but have subsidiary origins and insertions apart from those of the fibres 
which make up the muscle as a whole ; some of these local fibres may 
serve to modify the elasticitj^ and consistence of the cord, while others 
may tighten the segments of the cords in front of their attachment and 
slacken those behind. 

The arytenoid muscle is a square bundle attached to the posterior con- 
cave aspects of the arytenoid cartilages (Fig. 234). Most of the anterior 
fibres are transverse and extend directly across to be attached to the 
outer half of the concave surface of the opposite cartilage. The more 
posterior or dorsal fibres are inserted variously in the lateral laryngeal 
walls, while the intermediate fibres run partly independently and partly 
with the uppermost fibres of the thyro-arytenoid into the inner and 
outer walls of the saccules of the ventricles. The latter are sometimes 
known as the aryteno-epiglottidean muscles. The modern view is to 
regard the arytenoid muscle as a continuation of the thyro-arytenoid 
and as exemplifying the existence of a glottic sphincter. The muscle 
draws the two arytenoid cartilages together, which approximation when 
complete is accompanied by depression, owing to the shape of the crico- 
arytenoid joints. It is supposed that in swallowing the two arytenoids 
are drawn together and at the same time forward, so that their upper 
ends come in contact with the posterior surface of the epiglottis. 



CHAPTEE XII. 



EXAMINATION OF THE LAEYNX. 



The i^atient should be seated as for examination of the pharynx. 
Light may be obtained from any good lamp, Argand gas-burner, or 
electric source. The fixture should be so constructed as to be easily 
raised, lowered, and turned from side to side (Fig. 236) . A very useful 
apparatus is a Welsbach gas-burner on an Argand frame and moving up 
and down on the standard of a student-lamp. If the source of light be 
electricity, the bulb must have a glass covering of such construction 
that the shadow of the incandescent filament shall not interfere with 



Fig. 236 




Ik' 






'c=; 



Mackenzie's gas-bracket. 



the clearness of the image. The Phillips photoi^hore (Fig. 237) meets 
all necessary requirements in this respect. The head-mirror is worn 
as for examining the pharynx. It may be fastened to a rod running 
from the condenser (Fig. 238) or worn on the usual head-band (Fig. 
239). In the latter instance it should be placed over the eye corre- 
sponding to the side of the examiner on which the light is placed : the 
latter should be at the level of the top and a little behind the i^atient's 
ear. In addition there is needed a laryngoscopic mirror (Fig. 240) with 

589 



590 



DISEASES OF THE LARYNX. 



a diameter of one inch, the glass being at an angle of one hundred 
and twenty degrees with the handle. The i^atient having been suitably 
placed with back straight and the body very slightly inclined forward, 
he protrudes the tongue, which is grasped in a napkin or towel held by 
the examiner, the latter' s left thumb being above and his forefinger 

below the tip of the organ. Care must 
Fig. 237. be taken not to pull on the tongue, 

and the forefinger must be held just 
above the level of the lower incisor 
teeth, so that as the tongue is gently 
held down it shall not come in sharp 
contact with the incisor edges. The 
examiner next warms the laryngeal 
mirror by holding it at a little dis- 
tance from the flame (or spirit-lamp 
if electricity is used) until the thin 
film which immediately appears on 
the glass is dissii)ated. Before each 
insertion of the mirror it should be 
cleansed, warmed, and tested on the 
examiner's own skin. 
The shaft of the mirror should be held by the examiner exactly as he 
would hold a pen-holder. The above manipulations having been com- 
pleted, the mirror is passed with glass downward and the shaft held away 
towards the angle of the mouth until the point of junction of the shaft 
with the mirror reaches the base of the uvula. Then, by a movement 
upward and backward, the uvula will be made to lie on its posterior sur- 




The Phillips photophore. 



Fig. 238. 




Shade and condenser. 

face, which will also partially support the edges of the soft palate, and 
the distal rim of the mirror will be in contact with the posterior pharyn- 
geal wall. The patient is directed to phonate a vowel of high pitch, 
which act depresses the base of the tongue, lifts the epiglottis, and brings 
into view the laryngeal cavity. While the parts are in this position the 



EXAMINATION OF THE LARYNX. 



591 



patient may be directed to take a few deep and ra^Did breaths, as they ex- 
aggerate the normal excursions of the vocal cords and at once determine 
their condition as to motility. 

Fig. 239. 




Pomerov's head-mirror. 



In some instances the patient will do better to hold the tongue him- 
self in the manner described, thus leaving both hands of the examiner 
free. This is of course necessary in all instrumentation for therapeutic 



Fig. 240. 




Throat-mirrors. 



purposes. Some writers suggest that if the patient is allowed to hold 
a small hand-mirror during examination he will see just what is wanted 
on his part, and will more readily co-operate with the examiner in 
securino: the desired relaxation of the various structures. The fore- 



592 



DISEASES OF THE LARYNX. 



going seems to be very easy of accomplishment, bnt practically it is 
extremely difficult, and at times at the first examination absolutely impos- 



FiG. 241. 




Diagram showing the principle of laryngoscopy. (Bosworth.) 
Fig. 242. 




Diagrammatic view of tongue-base, epiglottis, arytenoids and aryegiglottic folds, ventricular bands, and 
vocal cords, with the laryngoscopic reflection. A polyp shows below the left cord. (Schrotter.) 

sible. This arises partly from fear on the part of the patient and partly 
from the natural irritability of the i)arts. The patient should be assured 



EXAMINATION OF THE LARYNX. 



593 



that tliis is only au examination and a procedure absolutely free from all 
j)ain. It is often well to partially insert and then withdraw the mirror 
several times before any real attempt is made to get a view of the parts^ 
and the natural irritability may be overcome by having the patient suck 
ice-pellets for a few minutes. In cases of moderate irritability it may 
suffice to gently swab the fauces with a weah solution of cocaine or 
eucaine several times before the insertion of the mirror. If there is much 
acute inflammation of any of the throat structures a sedative inhalation 
may be used every few hours for a day or two. In the worst cases the pa- 
tient should be directed to gargle the throat every two hours with a strong 
bromide solution (to be afterwards swallowed) for a few days, by which 
time it will generally 

be feasible to complete Fig. 2-t3. 

the examination. 

In regard to chil- 
dren, the advice of 
Lennox Browne may 
here be quoted. ^'I 
take every step exactly 
as with an adult, only 
di ffer i n g, p e r h a p s, 
in saying less rather 
than more to the pa- 
tient beforehand ; for 
telling a child that he 
is not going to be hurt 
is often the first sug- 
gestion that he may 
be.*' He summarizes 
the difficulties of in- 
fantile laryngoscopy 
as, first, a refusal of 
the child to open the 

mouth, to be overcome by a little patience or compression of the nostrils, 
when the patient must open the mouth to breathe ; second, refusal to 
protrude the tongue, which indeed is not really necessary ; and, third, 
the pendent position of the epiglottis, for which, if the first two have 
been overcome, the examiner may rely on the advantage of reflex 
gagging, which will permit of a fair, though momentary, view of the 
parts it is desired to inspect. 

Kirstein, of Berlin, has recently introduced or rather revived the 
method of direct examination of the laiynx and of the posterior wall. 
"Orthoscopy" instead of "autoscopy'^ has been suggested as a name 
for this method, since the former conveys the meaning that in this pro- 
cedure the laryngotracheal axis is made to form more or less of a straight 

38 




Kirstein's laryngoscope with electric-light attachment and inter- 
changeable depressor. (Thorner.) 



594 



DISEASES OF THE LARYNX. 



Fig. 244. 




line with, the buccal cavity. The method is of limited application ouly^ 
for but few patients are able to bear without resentment of the parts 
the prolonged and somewhat painful manipulation which the method 
necessitates. The relative positions of patient and examiner can be 
appreciated by reference to the figure. 

The instrument consists of, first, a spat- 
ula fourteen centimetres long, and notched 
so as to fit against the median glosso- 
epiglottic ligament. The general shape 
of the spatula accommodates itself to the 
parts which it is to fit 5 second, a hood 
which is attached to the front end of the 
spatula and serves to keep the passage 
clear (for this hood Thorner has substi- 
tuted a flat plate, which makers the instru- 
ment less cumbersome and just as efficient) ; 
third, the handle of the spatula set at right 
angles and carrying cords for attachment 
to the electroscope. It will be seen that 
by this method the examiner looks di- 
rectly down upon the cords themselves 
instead of upon a reversed image of them, 
as by the usual mirror method. The Kir- 
stein method has not come into general 
use, as the apparatus is somewhat ex- 
pensive and instruments for operative 
work with it must all have a special shape. 

The X-ray has also been used for examination of the larynx. It is 
useful to detect tumors and foreign bodies, but, as a rule, whatever infor- 
mation it gives can be obtained by less cumbersome methods. Freuden- 
thal has applied the principle of translumination in examining the 
larynx by means of a 
device here figured. 
A yellowish-red light 
is thrown through 
the laryngeal tissues, 
making their appear- 
ance quite different 
from the ordinary. 

Finally, mention 
may be made of the 
method of Killian for 
getting a view of the posterior wall of the larynx. The patient stands 
with head well bent forward, while the examiner kneels in front of him, 
holding the mirror up against the uvula. It must be borne in mind, 



Position of neck and head during 
examination with the electric ortho- 
scope or autoscope. (Thorner.) 




Freudenthal's electric lantern for translumination of the larynx. 



EXAMIXATIOX OF TPIE LAIlY^s'X. 595 

however, by beginners that the change in the angle of the mirror changes 
the apparent customary relation of the parts from that of the ordinary 
laryngeal image. In the Killian method the epiglottis appears in front 
and the i)osterior laryngeal wall behind. 

The Laryngeal I:\rAGE. — Eeference to previous figures will show 
that the laryngeal image is reversed in an antero-posterior direction, and 
that portion of the larynx which is really farthest from the examiner 
seems nearest to him in the picture. There is no reversal of lateral posi- 
tion. "Wliat is right or left in the mirror is right or left in the larynx. 
In addition, the examiner must remember that he is sitting opx^osite to 
the patient, so that his own right is the latter* s left. To the practised 
observer all these points are familiar, and he unconsciously makes the 
necessary allowances, so that his description of what he sees is definite 
and accurate as to anatomical site, but the beginner may find some diflQ.- 
culty in taking into proper account all these peculiar relations. 

The first object coming into view will be the epiglottis. Backward 
and downward from this run folds of mucosa, one on each side to the 

Fig. 246. 





Laryngeal image during breathing. Laryngeal image at the beginning of 

(Bresgen.) phonation. (Bresgen.) 

arytenoid cartilages, which appear as small knob-like bodies in the 
median line in the lower part of the image, which separate and approach 
very slightly in ordinary breathing, coming snugly together on phona- 
tion. These folds form the lateral boundary of the top of the larynx. 
On each side is the pyriform sinus, a locality which should always be 
carefully inspected when looking for foreign bodies. In each fold, nearer 
the posterior than the anterior portion, will be seen the rounded jDromi- 
nences of the cartilages of Wrisberg. The cornicula surmounting the 
arytenoids are i:)ractically indistinguishable from them. 

Below the aryepiglottic folds are seen the ventricular bands or false 
cords, which extend from the receding thyroid angle to the arytenoid 
cartilages ; they are reinforced by the thyro-arytenoid ligaments and are 
parallel to the true cords. Just below them are the ventricles of the 
larynx, and forming the inferior border of these, the true vocal cords. 
Perhaps the word pearl-gray describes their color as well as any. Between 
the cords is the rima, or chink of the glottis, constantly changing its shape 



596 DISEASES OF THE LARYls^X. 

in breathing and pronation. The vocal process sends a niinnte cartilagi- 
nous prolongation into the cord, which is seen just in front of the latter' s 
attachment to the arytenoid. Under some circumstances it is possible 
to hold the mirror so as to get a glimpse during deep inspiration down 
the trachea, even to its bifurcation. 

An estimation of the exact normal color of the laryngeal mucosa and 
contour of its various parts can be acquired only by practice. Here, 
as elsewhere, there are variations in appearance perfectly compatible 
with health and proper function. This is especially the case with the 
vocal cords, which vary greatly in color. 

PHYSIOLOGY OF THE LARYNX. 

The function of the larynx is twofold. It presents movements syn- 
chronous with those of breathing, and is also concerned in voice i^roduc- 
tion. With every act of inspiration there is a slight outward rotation of 
the arytenoids on the cricoids by means of the contraction of the posterior 
erico-arytenoid muscles, and in addition there is an outward rocking of 
the arytenoid on the cricoid so as to open the glottis as widely as possible. 
In exi:)iration the muscle simj)ly relaxes and the air passes out through 
the glottis in a passive way. The contraction of the above-named muscles 
is a reflex act originated by the direct stimulus of the blood, with dimin- 
ished oxygen, on the respiratory centre in the floor of the fourth ventricle. 
In quiet respiration these movements of the larynx are barely i)ercepti- 
ble, but a slightly increased depth of breathing will at once bring them 
into play. 

Furthermore, the epiglottis has a certain function in the act of deglu- 
tition. Much stress was formerly laid on its office as a ' ' lid' ' to the 
laryngeal box to prevent the entrance of food into the latter, but it can 
be removed in animals without impairment of the act of swallowing, and 
in man is frequently wanting as the result of various destructive pro- 
cesses, yet after the patient has learned to accommodate himself to the 
altered condition he can swallow without danger or even difficulty. 
Stuart and McCormack ^ have shown that in the act of swallowing the 
epiglottis projects upward in close contact with the base of the tongue. 
The cartilage has also been regarded as a ^'sounding-board" reflecting 
the vocal wave to the pharynx, where it is in part articulated. If the 
edges of the cartilage are irregular and ragged the voice is apt to become 
rough and harsh, and if the cartilage is entirely destroyed the voice is 
much less distinct. 

The act of phonation is essentially a vibration of the column of air 
in the upper passages, induced by the partial arrest of the respiratory 
current driven through the narrow slit formed by the approximation of 
the vocal cords and moulded by the structures higher uj) into articulate 

1 Jour. Anat. and Physiol., 1891-92, vol. xxvi. p. 231. 



EXAMIXATIOX OF THE LARYNX. 597 

speech . The muscles which approximate the cords are the lateral crico- 
arytenoids and the interarytenoid. Their combined action is very sim- 
ple ; the tension of the cords is a matter somewhat more complicated. 
Concerning tension, Bosworth notes that it is not so much a matter of 
stretching the vocal cords to their greatest possible length as it is of 
holding their edges in a state of firmness and rigidity, whether the 
opening between the edges be a straight line or oval. The cricothyroid 
muscle draws the cricoid cartilage upward and backward, thus length- 
ening and rendering tense the cords. Finer tension is regulated by the 
thyro-arytenoid. The apparent action of this muscle would seem to be 
to relax the cords by the approximation of their two attachments, but the 
cords themselves are in a sense the aponeurosis of this muscle on each 
side, so that the action of the latter through the whole extent of the 
cords seems to increase tension and to give it a finer adjustment. More- 
over, it is supiiosed to act as a damper, checking the over-vibration of 
the sonorous media. 

There are, then, two sets of muscles, one of which controls the width 
of the glottic opening, the glottic openers or abductors and the glottic 
closers or adductors ; and, second, the group which effects the tension of 
the vocal cords ; both sets act together in vocal production : the varying 
positions of the cords are the resultants of this combined action ; hence 
the difficulty of too definitely assigning to any one muscle a unique action 
outside of which it never varies. 

An interesting study of the function of the ventricular bands in i)hona- 
tion has been made by Dogodany,^ who found that in sixty-two per cent, 
of one hundred and fifty cases examined the ventricular bands presented 
movements during j)honation. It is possible, under various pathological 
conditions, for these false cords to assume the functions of the true cords 
and to act as supplementary constrictors of the glottis. 

Reference may briefly be made here to one of the triumphs of modern 
surgery and after-care in the successful removal of malignant tumors of 
the larynx and the complete extirpation of that organ, with the subsequent 
development, owing to the wonderful adaptive powers of nature, of a 
voice which has answered all the necessities of life. Such a case was 
exhibited some years ago by Cohen, in which all communication was shut 
off between the trachea and the mouth. The patient seemed to swallow 
the air, which distended the lower pharyngeal cavity, whence it was ex- 
pelled in phonation by the pharyngeal muscles. While articulation was 
produced by the lips and tongue, there was some doubt as to what the 
vibrating medium really was. It was variouslj^ considered by those who 
examined the case to be the soft palate, edges of the pharyngeal con- 
strictors, etc. 

^ :\Ionatsschr. f. Ohrenh., 1899, Bd. xxxiii. S. 10. 



CHAPTEE XITI. 



ACUTE INFLAMMATIONS OF THE LARYNX. 



These may be of the simple exudative variety, coming on alone or as 
a complication of many systemic states and general fevers. In addition, 
there are the acute conditions due to specific causes, such as syphilis and 
tubercle, and those attended by membranous formation, such as diph- 
theria, true and false. 

Acute Cataerhal Laryngitis. — This is an exudative inflamma- 
tion of the mucous lining of the larynx, the peculiarities of which in this 
situation are due to anatomical conditions. 

Etiology. — Modern views incline to the belief that acute catarrhal 
laryngitis is in the majority of cases the result of the lighting up into 
an acute stage of a chronic catarrhal process either in the larynx itself 

or in the adjacent tissues. All those whose 
occux3ations subject them to much dust 
have their upper air-passages in a state of 
constant irritation and hypersemia, which, 
under the exciting influence of fatigue, ex- 
IDOsure to cold and damp, etc., readily takes 
on an acute condition. Inhalation of to- 




Acute laryngitis. (Krieg.) 



bacco-smoke in a confined space, of irri- 
tating odors and fumes of all sorts, abuse 
of alcohol, and excessive vocal effort are all 
liable to be followed by acute inflammation. 
Several drugs are capable of setting up the 
disease, especially potassium iodide, and 
Bethi^ has reported a case due to arsenic. 
It occurs at all ages, and is more common in men, doubtless from the fact 
that they are more exposed to irritants. In children a cold in the head 
is apt to travel downward, while in older people the brunt of the attack 
seems to fall first of all on the larynx, while the parts above become 
secondarily affected. 

Pathology. — In a case of ordinary severity the submucous tissue is not 
affected. There is the usual sequence of vascular contraction, quickly 
followed by dilatation and arrest of secretion. The dry stage is apt to 
last longer here than in other mucous membranes 5 it is succeeded by the 
exudation of serum in small quantity and increased production of mucus. 
Naturally, the process appears most marked at those sites in which the 



AVien. Med. Presse, 1897, S. 326. 



598 



ACUTE INFLAMMATIONS OF THE LARYNX. 599 

mucosa is loosely related to the subjacent parts, as on the ventricular 
band, interarytenoid commissure, and aryepiglottic folds (Fig. 247). Be- 
tween the arytenoids the mucosa frequently presents rugae which suggest 
the unevenness of an ulcerative i)rocess (Fig. 248). The true cords show 
only vascular dilatation, and the lesion does not, as a rule, extend below 
the glottis. The increased secretion contains desquamated epithelial 
cells and emigrated lencocytes. The lesions may be confined to very 
definite areas in the larynx, while surrounding portions show no change. 

Syynjjtoms. — Ordinarily the constitutional symptoms, if indeed pres- 
ent, are of the mildest possible degree, consisting of a slight fever with 
moderate general malaise. Local pain is not usually felt, though the 
general region of the larynx may be sensitive on manipulation. The oc- 
currence of cough signifies an involvement of those areas which Stoerk 
called twenty years ago ^' cough spots.*' These are the posterior sur- 
face of the larynx, the interarytenoid fold, the bifurcation of the trachea, 
and the under surface of the vocal cords. As Bosworth points out, 
under these circumstances a cough of any severity probably means the 
existence of a mild tracheitis and not a laryngitis pure and simple. 
Glaiiy mucus may be expectorated, but swallow- 
ing is generally not much interfered with. ^''^ 248. 

The most obvious symptom and the one 
giving the patient the greatest concern is the 
partial or entire loss of voice. Partial loss is 
attended by alterations in quality, so that the 
patient speaks with more or less hoarseness. 
Even when audible phonation is possible it 
requires some effort, and patients are apt to Rugaa of interarytenoid space 

voluntarily confine themselves to a whisper. simulating ulceration in simple 

The quantity of exudation posteriorly is rarely ^^^^^""^ '^'^""^'- ^^- ^- ^" 
sufficient to prevent approximation of the cords. 

Moreover, it is evident that the action of the delicate muscles of phona- 
tion, some of which are practically embedded in the mucosa, must be 
greatly interfered with, a fact which would amply account for vocal im- 
pairment. In this simple form of the disease in the adult dyspnoea is 
wanting. 

E. J. Moure ^ has described a form of laryngitis seen in association 
with recent influenza outbreaks. The brunt of the attack is borne by the 
arytenoid region, which becomes intensely' red and tumefied. Dysphagia 
is marked and i^ersistent, and the cases are distinctly worse at night. 
They last from five to eight days and are without sequelae. 

Diagnosis. — Examination of the larynx sometimes shows but little 
evidence of inflammation, but a general congestion of varying intensity 
with a redness of the cords may be expected. Caution must be ob- 

^ Eevue hebd, deLaryngoL, 1900, Xo. 29, p. 77. 




600 



DISEASES OF THE LARYNX. 



Fig. 249. 



a^' 




Hemonhagic larj ngiti-<. (Kneg ) 



served, however, in diagnosing the condition from the latter alone, for 
in male vocalists the cords are often of a reddish -pink color, even under 
normal conditions. In women, however, redness is to be considered 
(unless the patient habituallj^ drinks wine freelj') abnormal congestion. 
The latter is naturally most marked where the attachment of the mu- 
cosa to the underlying parts is loose. In mild cases the small vessels of 

the cord stand out in contrast with the whitish 
appearance of the cord itself. From this con- 
dition the disease may progress through all 
grades of severity, some cases being attended 
by hemorrhagic symptoms and the expectora- 
tion of blood after a violent attack of coughing. 
Under these circumstances there is generally 
found a circumscribed i^atch where a eujper- 
ficial vessel has ruptured. This is the hemor- 
rhagic laryngitis of some writers (Fig. 249). 

The increase in size and number of vessels, 
the lessened resistance of their walls, and the 
periodical increase of blood-pressure from 
clearing the throat predispose to this acci- 
dent. If the process should become severe enough to involve the sub- 
glottic area, a rounded projecting mass underneath each cord, encroaching 
more or less on the lumen of the air-tube, may be expected (Fig. 250). 

In the mildest type of cases the excursion of the cords is scarcely at 
all interfered with, but in more severe types the interarytenoid swelling 
prevents perfect adduction, while abduction is not at all disturbed. It 
may happen that, owing to purel}' catarrhal causes, there is a partial 
paresis in one or more muscles, and there occur 
the peculiar appearances incident to these re- 
spective conditions. Perhaps the most common 
is an elliptical shai)e of the rima due to impaired 
action of the thyro-arytenoid muscles ; also there 
may be a triangular space between the posterior 
extremities of the cords due to imperfect function 
of the interarytenoid muscle. Bosworth inclines 
to the view that these are rather unnecessary re- 
finements, and that the mechanical conditions 
present from swelling amply account for the clini- 
cal picture shown. 

Course and Duration. — The disease runs its course in from seven to ten 
days, usually subsiding without special incident or sequel. It is never 
fatal, and is of importance only to those whose occupation renders vocal 
integrity necessary. 

Treatment. — "While general medication is not, as a rule, called for, it 
is well to act on the bowels freely, and to give a full initial dose of 



Fig. 250. 




Subglottic cedema. (J. 
Cohen.; 



ACUTE IXFL A M:\rATIOXS OF THE LARYNX. 601 

quiiiiue or Dover's powder, wliicli often lias the happy effect of break- 
nig up the attack. Aconite may be given up to its physiological effect, 
or small doses of bromide in combination with a little paregoric. Ser- 
viceable measures are a hot bath, followed by quick drying and getting 
immediately into bed, a mustard foot-bath, etc. The exquisite sensitive- 
ness of the interior of the larynx renders only the mildest measures ap- 
plicable during the acute stage. Inhalation of sedative vapors is often 
grateful, and for this purpose there may be used a mixture of menthol 
(half a drachm), eucalyptol (six drachms), and comi^ound tincture of 
benzoin (three ounces), one teaspoonful being placed in a pitcher or 
other vessel containing a pint of boiling water, and covered about its 
top with a folded towel, which serves the purpose of a funnel. In- 
halation may be continued as long as steam is given off, but care should 
be takan that the i^atient does not go out into the open air for some 
twenty minutes afterwards. Comi:)ound tincture of guaiac is by some 
preferred to the benzoin. These measures do not shorten the attack, 
but they alleviate the sufferings of the patient during its severity. If 
the case is seen before actual exudation has occurred, the use of a weak 
si^ray of suprarenal extract may by depletion of the vessels abort the 
attack. 

After the acute symptoms subside topical applications may be made. 
In fresh cases thej' should be effected by spraying a very weak solution, 
say of silver nitrate not over three grains to the ounce, or of zinc acetate 
not over ten. If the case becomes sluggish and there seems to be jxirtial 
paresis of the cords, iron salts may be used, one part of the muriated 
tincture and two of glycerin being apj)lied in spray or by means of a 
soft cotton brush. The latter method of application has been objected 
to as likely to injure the delicate tissues of the larynx, but this need 
not result if one is careful. A most useful instrument for this purpose 
is the Heryng laryngeal applicator, which consists of a curved shank 
terminating in an oval loop, down which travels a screw collar. The 
loop may be threaded with a wisj) of cotton, held in by the collar, and 
by unscrewing the latter after use the cotton can be instantly withdrawn. 
No objection can, therefore, be made on the score of lack of cleanliness, 
as is the case with the ordinary sponge or brush. The wisp of cotton 
may be left long, so that after it reaches the level of the cords and spasm 
is excited the medicine is squeezed out of the cotton and bathes the 
tissues without the least injury from the instrument. The use of various 
kinds of throat lozenges is at best unreliable, unless they contain such 
agents as muriate of ammonia or cubebs, which are volatile at the tem- 
peratm^e of the body. 

If examination of other parts of the upper air-tract shows that the 
laryngitis has been su]3erinduced by the condition of the former, treat- 
ment suited to each case should at once be instituted, in order to i^revent 
a repetition of the attack. The nose and nasopharynx should be care- 



602 DISEASES OF THE LARYNX. 

fully cleansed and mild astringents apjDlied, giycerite of tannic acid being 
useful for tliis purxDOse. 

In regard to the restoration of vocal power in the quickest time pos- 
sible, there is no plan that will yield invariable success. Much can, 
however, be done by keeping the patient absolutely quiet, with entire rest 
to the larynx, speech being forbidden, and cold may be applied to the 
larynx, preferably by means of the coil. The room should be at the 
temperature recommended for the sick (70° F.), and the air charged 
with moisture. A weak solution of silver nitrate may be applied to the 
larynx, and repeated, if necessary, once, or at the most twice, during the 
day. A saline should be given to keep the bowels open, and the exhi- 
bition of aconite up to the physiological effect, and preferably in the 
form of aconitine in small and repeated doses, sometimes has marvellous 
effects. Patients should be warned of the risk they run in trying to 
work while the vocal organs are still in such a sensitive condition. A 
moderate use of coca wine will sometimes help to tide over a crisis. 

A. Abrams^ has suggested a novel plan for the relief of the aphonia 
and dysphonia of acute laryngitis. ^' First, one should mark approxi- 
mately with a pencil on each side of the neck the point in the thyro- 
hyoid membrane where the internal laryngeal branch of the superior 
laryngeal, the nerve of sensation to the larynx, passes into the latter 
organ. Over the points marked with the pencil, methyl chloride or a 
spray of rhigolene is to be used to freeze the parts. The relief in most 
instances is almost instantaneous, and phonation, which was before diffi- 
cult or painful, can be performed with perfect ease. In some instances 
the relief is of short duration only, in which cases freezing must be 
applied again or several times. This same method may be employed 
with advantage in neuroses of the larynx like laryngismus, spastic apho- 
nia, and in the pharyngeal crises of tabes dorsalis." 

Acute Catarrhal Laryngitis in Children. —The larynx of the 
child differs from that of the adult not only in size but in anatomical 
structure, in that the mucosa is more vascular and more loosely attached 
to the parts beneath. Moreover, there is often a more definite limitation 
of the disease, which appears above the cords in mild and below in 
severe symptoms. 

Mild Form. — This form is practically the same as seen in adults. It 
occurs at any age up to twelve years, more commonly under four or five. 
It may form part of an acute catarrh, involving the entire upper air-tract, 
or be limited to the larynx. The disease in the child is more apt to be 
marked by a slight febrile movement and general malaise. Local symp- 
toms are mild, the voice being moderately hoarse but rarely lost, and 
there is generally considerable tenderness of the parts on manipulation. 
The local changes are confined to the same areas as in the adult. 



Therapeutic Gazette, November 15, 1898, p. 72( 



ACUTE INFLAMMATIONS OF THE LARYNX. 603 

An attemi)t should always be made to examine the larynx, though in 
a very young child the examiner may be able to get only a momentary 
or no glimpse at all. The condition is not fraught with danger, and will 
generallj' subside in a week or a little over. A possibility is the exten- 
sion of the inflammation to the parts below the cords, when the status of 
afl'airs becomes quite different. The necessity of an accurate diagnosis 
is the main feature, as any malady that interferes with the integrity of 
the larynx should always be most carefully diagnosticated. If symptoms 
become progressively worse with reference to the passage of air, it is evi- 
dent that there may be present a more severe disease to deal with than 
a mere catarrhal change. 

The bowels should be moved by castor oil, and some application made 
to the chest and well rubbed uj) into the neck. For this purpose Stokes's 
turpentine liniment, diluted with a little bland oil, so as not to be too 
strong for a child's skin, may be used. It is often impracticable to give 
a child inhalations, although it may be kei^t in a medicated atmosphere 
in a small room, while internally some preparation of ammonia, with a 
little paregoric, should be given in small doses. If the attack has seemed 
to come from an acute rhinitis, application to the nasal mucosa of a very 
weak cocaine solution, or of suprarenal extract followed bj^ nasal irriga- 
tion, will often effect a cure. 

Severe Form. — In the severe form the brunt of the inflammation is 
borne by the subglottic tissues, and there is a consequent obstruction to 
the air-conduit giving rise to symptoms of great gravity. This form of 
disease is variously known as Mse, crowing, or spasmodic crouj), laryn- 
gismus stridulus, etc. It is well to avoid the use of the word croup and 
its derivatives, exce]3t as referring to a definite variety' of pathological 
change the most obvious exj)ression of which is the formation of a false 
membrane. 

The causes of the severe subglottic type are in general the same as 
those of the milder forms. It may occur in all classes of children, though 
most attacks are found in those who are disposed from any cause to 
lymphatic overgrowth, the ' Mymphatism' ' of the French school of 
pathologists, as these children constantly suffer from upper air-tract 
catarrhs, but attacks may frequently be referred to some dietetic error. 

The pathological change is not unlike that of the mild form, but there 
is undoubtedly an engorgement of the lymphatic vessels, which at this 
site in the larynx are esj)ecially numerous, and which j)i'ess forward the 
structures overlying them into the lumen of the air-tube. 

The symptoms are of the same general variety as in the mild form, 
but much more severe, and fever may j) recede, follow, or be simultaneous 
with the local manifestations. There is dyspnoea, which is continuous, 
but presents exacerbations, stridulous cough and voice, and perhaps 
complete aphonia. The character of the cough is compared by Bosworth 
to that seen in aneurism or other thoracic tumors pressing on the trachea. 



604 DISEASES OF. THE LARYXX. 

It is at the outset dry and harsh from arrest of secretion, it occurs in 
paroxysms, and the inspiratory stage has a peculiar crowing character. 
Boys are more often affected than girls. 

A noteworthy feature of the disease is the nocturnal exacerbation. 
The child may be only slightly sick on retiring, but after a few hours' 
sleep it suddenly awakes with a severe paroxysmal cough and dyspnoea. 
This forms the 'laryngismus stridulus" of some writers. The typical 
attack presents these exacerbations on three or four successive nights, 
the second generally being the worst. They usually subside as soon as 
the membrane is moistened by the various therapeutic measures adopted, 
or the patient dislodges from the larynx the accumulated mucus. 

In establishing a diagnosis an attempt should alwaj^s be made to get a 
view of the larynx, but practically this is possible in only a very few of 
the cases. The question simply resolves itself into whether or not the 
child has diphtheria. As shown by Syme, most of the membranous 
croup of former writers is really diphtheritic in character. Dix)htheria 
does not always present a membrane in the pharynx at the time of the 
laryngeal deposit, but this matter is treated more in detail in the chajDter 
on that disease. An opinion must be formed here from the general 
objective symptoms, the night attacks, the improved condition in the 
daytime, the higher fever, and the more active type of constitutional dis- 
turbance suggesting catarrhal disease, while the marked prostration , the 
progressive character of the symptoms, and the evidences of systemic 
blood-i)oisoning indicate diphtheria. 

Acute catarrhal laryngitis generally runs its course in a week or so, 
and recovery is the usual result, the fatal cases being referable to a 
complicating capillary bronchitis or lobular pneumonia. 

As to the treatment, the chronic condition of lymphatism in which 
many of these children are demands iodine in some form. The syrup 
of the iodide of iron or of hydriodic acid may be given in iDroper dose. 
The former is well combined with cod-liver oil, and must be continued 
for some months in order to secure a permanent result. Proper direc- 
tions as to clothing, bathing, and food must be given, and, if necessary, 
enlarged glands and tonsils must be removed by surgical measures. 

For the acute attacks the child should be kept in a warm atmosphere 
saturated with moisture, and calomel or gray powder in two- or three- 
grain doses should be immediately ordered. Preparations of ammonia 
with Tolu syru^D should be given in order to re-establish secretion. 
Opiates are to be avoided, but if a sedative mixture seems necessary to 
obtain quiet, preference should be given to codeine or the newer remedy, 
heroin, in very small dose. 

In the acute nocturnal exacerbations the principal aim should be to 
clear out the larynx, and for this it has been customary to use various 
emetics, with a view to relaxing the supposed laryngeal spasm ,• but, as 
has been said, there is no positive proof that this exists ; hence an 



ACUTE IXFLAMMATIOXS OF THE LARYNX. 605 

equally good effect cau be obtained from derivative raeasures, sucli as a 
liot mustard-bath. Warm inhalations may be tried, and if vomiting is 
desired, it can be obtained more x)romptly by the finger than by depress- 
ant remedies. Hot fomentations are also indicated. In cases in which 
all these measures fail to relieve dyspnoea, inhalation of amyl may be 
tried, or some form of instrumentation. In some cases the passage of a 
flexible male or a hard female catheter will afford relief. The intubation - 
tube and tracheotomy are at the surgeon's disposal, but such radical 
measures as these are rarely called for. 

Croupous Laryngitis. — This is the condition known as membranous 
laryngitis, or true croup, and is characterized by the api^earance in the 
larynx of a false membrane due to bacilli other than those of diphtheria. 
The duality or not of the two affections has been and still is a matter 
of much discussion among bacteriologists and clinicians. Many cases 
formerly regarded as membranous laryngitis would now undoubtedly 
be considered diphtheria ; but there seems to be a group of cases not 
purely diphtheritic, nor, in foct, from a bacteriological stand-point, 
diphtheritic at all. to which the name croui^ous laryngitis may properly 
be given. 

Etiology. — The maladj' is without doubt a germ disease, but it remains 
to be seen whether one particular micro-organism is the exciting cause 
or whether this i)roperty may not be shared hj several of a grou}) of ba- 
cilli. Whatever germ may be the cause, it undoubtedly commences its 
action high up in the fauces and gradually works downward. Few 
cases occur after the ninth j^ear, the earlier years of childhood being 
the most suscex3tible, and some children show this proclivity more than 
others. As in the nose, so in the larynx there occurs an inflammation 
attended by the formation of a false membrane without the existence 
of a true diphtheria. It is evident that the use of the word diphtheria 
as signifying simply a membranous exudate is no longer permissible, 
as the latter requires a qualifying term referring to the bacteriological 
cause. 

There may be, it is true, membranous laryngitis from other causes 
than idioiDathic germ invasion. Thus, Price Brown records the case of 
a woman twenty -five years of age whose tonsils he had cauterized with 
the galvano-cautery. Three days later a membrane appeared in the 
larynx, not continuous with that on the tonsil, but restricted to the ven- 
tricular bands and extending down to the true cords. Mild fever, com- 
plete aphonia, and moderate laryngeal stenosis were present. Steam in- 
halations and iron and glycerin internally led to a cure in five days, and 
no recurrence took place. Brown regarded the case as one of pure 
fibrinous deposit of staphylococcic origin. Other traumatic causes may 
be irritant inhalations, burns, scalds, etc., and various chemical agents 
used possibly in too strong solution. Traumatism may lead to a fibrinous 
deposit in the larynx, the former being of staphylococcic origin. Finally, 



606 DISEASES OF THE LARYNX. 

it remains to be said tliat this form of intralaryngeal inflammation may- 
complicate tlie exanthemata, especially measles and scarlet fever. 

Pathology. — The lesion consists of the formation of a false membrane^ 
which may ai)pear on any j)art of the surface of the larynx, either in 
continuous areas or in patches. The membrane is formed of fibrin, en- 
tangling in its meshes leucocytes, blood-cells, and desquamated epithe- 
lium, and removal leaves a bleeding surface. It is essentially an exuda- 
tive inflammation, with degeneration or death of tissue. The necrosis 
may involve only the epithelium, which passes into the condition of 
coagulation necrosis and forms part of the false membrane, or it may 
involve also the stroma. The death of the epithelium alone leads to 
simple erosions, that of the stroma to ulcers of varying size and depth. 

Symptoms. — There is a chill, followed by a febrile movement of rather 
high range and sthenic type, a full and bounding pulse, anorexia, con- 
stii)ation, diminished and high-colored urine, and considerable bodily 
pain. Swallowing is painful, the distress radiating to the ears. The 
throat symptoms begin to make their appearance as hoarseness and dysp- 
noea, with a stridulous cough. Difficulty in breathing is noted both in 
inspiration and expiration, as the air-conduit is narrowed. If the disease 
has begun higher up, and later extends to the larynx, this extension is 
generally marked by a sudden rise in the fever. Later the evidences of 
imperfect aeration of the blood appear, together with the signs peculiar 
to laryngeal stenosis, — viz., recession of the intercostal spaces, dilatation 
of the nasal alee, etc. Unless the condition is relieved, the patient gradu- 
ally dies from carbonaemia. 

Course and Frognosis. — The disease generally runs its course in from 
four to six days, by which time death ensues or resolution has begun. 
The prognosis is always grave, especially in children under three years 
of age. There is great danger of extension of the malady to the trachea 
and bronchi, a complication always fatal in spite of every therapeutic 
resource. 

Treatment. — The patient should be kept in a warm room and made to 
inhale the vapor from slaking lime. This should be done about every 
four hours, and in the intervals he should breathe the vapor of hot water 
constantly generated by a spirit-lamp in a kind of tent. A simple con- 
trivance is to tie a large oi)en umbrella to one corner of the bed and drape 
a sheet over it. Medicinal treatment should be begun with calomel, 
two grains of this or of the gray powder being given every two hours for 
the first day until the characteristic green stools appear. This is exhib- 
ited with the idea of limiting the plastic formation in the larynx. If 
there seems to be much loose membrane in the larynx an emetic may be 
administered to dislodge it ; for this purpose the depressing emetics 
with a constitutional effect should be avoided. A little salt in warm 
water will probably answer every purpose. If the fever is high, cold 
sponging may be used, and if the pulse is weak, alcohol should be 



ACUTE IXFLAMMATIOXS OF THE LARYXX. 607 

administered. Undoubtedly the remedy most frequently used is the 
time-honored muriated tincture of iron 5 of this a child of three years 
can take ten droits, well diluted with glycerin in water, every two or 
three hours. If all the foregoing fail to relieve the patient, resort must 
be had to either intubation or tracheotomy, the problem being to keep up 
a sufficient supply of oxygen until the membranous formation in the 
larynx shall have ceased. 

PHXEG^roxors axd cedematous laryngitis. 

It is hard to reconcile the classifications of certain laryngeal affections 
made by different authors, for, while some regard certain clinical mani- 
festations as merely symptomatic, others, under the same circumstances, 
use the name of the most j)rominent symptom as the designation for a 
distinct affection. This is notably the case with the phlegmonous and 
cedematous conditions now to be considered. It is preferable to follow 
the views of those who make two general designations, — (1) i)hlegmonous 
laryngitis and (2) oedema of the larynx. 

Acute Phxegmonous Laryxgitis. — By this term is meant an acute 
laryngeal inflammation of the mucosa occurring either without ax)parent 
cause or as a complication of acute involvement of surrounding parts. 
The peculiar features of the disease are its rapid onset, unusually active 
character, an^ the depth to which it extends. 

Etiology. — A predisi^osing cause is the i)resence of sepsis in some form. 
It has been looked ui:)on as essentially a larj^ngeal erysii)elas, though 
l^rimary cases are rare. Those instances referable to cold are doubtless 
more directly due to increased septic activity occasioned by the lowered 
vitality incident to the chilling. More commonly the affection is sec- 
ondary to the various forms of tonsillitis, i)ericervical suppuration, and 
the constitutional conditions incident to typhus, typhoid, small-pox, and 
dii^htheria. Some cases are referable to trauma from a foreign body, to 
inhalation of scalding vai)ors, to the ingestion of an irritant poison, and 
to influenza, as reported by G. A. Eichards,^ who notes that Mackenzie 
mentions thirteen cases, to which number his own statistics add twenty- 
six others collected from various sources. Many of them have been 
reported as idiopathic abscess of the larynx. 

Fatliology. — The first stage is one of engorgement of the vessels, quickly 
followed by a serous transudation. This is especially noticeable in those 
places where the mucosa is loosely attached to subjacent parts, such as 
the aryepiglottic folds, the ventricular bands, and the posterior aspect 
of the ei)iglottis. The mucosa covering these areas bulges, becomes very 
tense, and has a x)eculiar shining appearance. As a rule, the oedema 
does not extend to parts below. The exudation is generally symmetrical 
in appearance, and as the disease runs its course changes in character, 

1 Am. Jour. Med. Sci., INIay, 1890, p. 450. 



608 DISEASES OF THE LARYNX. 

becoming purulent. Abscess formation is more commonly unilateral, 
and occasionally the entire course of the disease seems confined to one 
side of the larynx. 

Symptoms. — These consist of a chill, followed by fev^r and the usual 
evidences of malaise. The difficulty in breathing and phonation from 
direct mechanical interference draws immediate attention to the seat of 
the disease^ the stridulous voice sometimes being the first local evidence. 

Diagnosis. — This is to be made by the use of the laryngeal mirror, sup- 
l^lemented, if need be, by digital examination. The enlarged ventricular 
bands and the posterior surface of the epiglottis will appear tense and 
projecting, with below and between them a triangular opening, which is 
the glottis. Palpation may determine the nature of the swelling and the 
presence or not of a foreign body. The history of the case will also afford 
valuable information. 

Course and Prognosis. — The disease generally lasts four or five days, 
and must receive the closest possible attention for thirty-six hours. If 
the dyspnoea has not reached the danger-point in this space of time, the 
inflammatory process will generally undergo resolution; but even if it 
goes on to suppuration, surgical intervention, so far as opening the air- 
passages, will not often be required. 

Treatment. — A brisk cathartic should be given at the outset. The ice- 
bag or the ice-water coil or leeches may be applied over the larynx 
externally, but main reliance must be placed upon early scarification of 
the inflamed area. If the dyspnoea be not too great and the patient have 
a fairly tolerant throat, this may be performed with a guarded bistoury, 
under the guidance of the index-finger 5 under other conditions the laryn- 
geal mirror should be used. The scarification should be repeated two or 
three times daily until j)ermanent subsidence of the swelling has taken 
j)lace. The possible necessity of a tracheotomy must always be borne 
in mind. In one case, in which sudden suffocation rendered it impossi- 
ble to do this in time, Macewen ^ passed an ordinary urethral catheter into 
the larynx. 2 

CEdema of THE Larynx. — This term has reference to a condition 
due to various affections. The oedema is practically the only lesion, there 
being no concomitant inflammation. 

Etiology. — One class of cases is due to trauma, such as that from poi- 
sons, caustics, inhalation of irritants, scalding by hot water or steam, un- 
skilful instrumentation, etc. ; another class is due to the effect of potas- 
sium iodide in too large internal doses ; a third class of cases is made up 
of those secondary to chronic visceral lesions, especially of the heart, 



^ Glasgow Med. and Surg. Jour. , 1879, vol. xi. p. 252. 

^ The combination of mechanical conditions generally renders the insertion of an 
intubation-tube impossible. Pus should be evacuated as soon as its presence can be 
determined. 



ACUTE INFLAMMATIONS OF THE LARYNX. 



609 



kidneys, and lungs ; a fourth class is associated with such acute general 
maladies as pyaemia and erysipelas ; while a final and large class comi)li- 
cates such local disorders as syi^hilis and tuberculosis of the larynx, carti- 
lage disease, and retropharyngeal abscess. 

Cases occurring without any apparent underlying cause are not un- 
common. Generally, however, careful inquiry will elicit the fact of a 
depressed physical condition due to hard work or overstrain from some 
soui'ce, or exi)0sure, to which the attack is directly referred. The latter 
may first expend itself upon the tonsils and uvula. Still another form is 
that due to the supposed angioneurotic oedema. 

Fathology. — This is suggested by the definition of the disease ; it is an 
oedema pure and simple. In a typical case the swelling presents itself 
as a three-sac exudation, composed of the aryepiglottic fold on each side 
and of the mucosa of the ei^igiottis in the middle. The ventricular bands 
and arytenoid commissure may also be invaded, while in some instances 
the oedema mounts over the top of the epi- 
glottis and apxDcars on its anterior surface. Fig. 251. 
Cases have been recorded in which the ven- 
tricular bands alone were involved, and oc- 
casionally the oedema may be unilateral. 
In cases complicating the exanthemata and 
general diseases the cervical tissues outside 
the larynx may also be invaded. 

Symptoms. — These are of sudden onset. 
The resj)iration suddenly becomes imj^aired, 
especially in inspiration, while expiration 
is not greatly interfered with. Inspiration 

becomes striduloUS in character, while the Early stages of oedema. (Krieg.) 

voice is deep, and later lost ; cough is often 

present, and is short and without expectoration. Pain is generally ab- 
sent, but may supervene if the cervical tissues become infiltrated. The 
laryngeal mirror will at once reveal the site and nature of the condition 
with which the surgeon has to deal. The exact picture differs according 
to the localization and limitation of the effusion. 

Frognosis. — The condition is always a grave one, and at the first ap- 
pearance of dyspnoea the medical attendant must be prepared for promj)t 
intervention. 

Treatment. — The cause of the condition should be ascertained, and 
treatment commenced in accordance with the findings. If heart disease 
is present, cardiac stimulants should be given hypodermically. Combi- 
nations of digitalis with strophanthus and small doses of nitroglycerin 
should at once be. injected. In liver and kidney diseases the bowels 
should be acted on promptly and the activity of the skin excited. The 
air of the room must be kept warm and saturated with moisture, the ice- 
coil may be used, as recommended for phlegmonous laryngitis, but the 

39 




610 DISEASES OF THE LARYIs'X. 

main reliance must be upon prompt and ttLOrough scarification, as pre- 
viously described under tlie heading of phlegmonous laryngitis ; in fact, 
the local treatment of the two is practically the same. 

DEFORMITIES, INJURIES, AND FHACTUEES OF THE LARYNX. 

Deformities. — In addition to the various deformities which result 
from different pathological processes, deformities may be due to defective 
development. Some of these which appear to be developmental may pos- 
sibly be due to congenital diathesis, especially the syphilitic, though this 
cannot always be determined. Seifert and Hoffa ^ found a congenital web 
in the larynx of a girl of sixteen, which was so hard that neither a knife 
nor an electric point would penetrate it. It was necessary to enter the lar- 
ynx from without (with previous tracheotomy) in order to effect division. 
The web was membranous posteriorly, but anteriorly it formed a thick cur- 
tain of tissue which i^assed forward obliquely, and was adherent to the 
anterior wall of the larynx about a finger' s-breadth below the vocal bands. 

Yarious other cases of membranous webs have been reported during 
the last few years. The symptoms of such a condition are the obvious 
ones of impaired air-supply, though in the quiet state no difficulty need 
be experienced. Treatment should consist in section of the web followed 
by systematic dilatation. 

Injuries. — So far as wounds not producing fractures are concerned, 
the general principles of modern surgical treatment apply, and no details 
need be given here. The resources of the surgical art of the present day 
enable one successfully to intervene in many cases formerly considered 
hopeless. The general iDlan to be followed is to approximate and retain 
in position all severed parts and to closely watch the breathing, being 
ready to intubate or tracheotomize as soon as serious respiratory em- 
barrassment is noticed. 

Concerning contusions, it need only be said that they present the same 
features as fractures, but to a less degree. 

Fractures. — These usually result from blows, falls, or sudden com- 
pression, and may involve one or all of the laryngeal cartilages. It is 
not an uncommon result of warfare. Owing to the ossification of these 
structures in later life, the accident is more commonly seen during that 
period. In sixty-two cases quoted by Bosworth from Durham's statistics, 
the thyroid was involved alone in twenty-four, the cricoid alone in eleven, 
and both cartilages in nine. The remaining cases were made up of various 
combinations of fracture of these and other cartilages. 

Symptoms. — The external appearance of the larynx varies according 
to the direction from which the trauma has come. If the force has been 
one exerting lateral compression, the anterior prominence of the organ is 
rendered even more noticeable. If the blow has come from the front, the 



1 Berlin. Klin. Woch., March 5, 1888, S. 192. 



ACUTE IXFLAMMATIOXS OF THE LAEYXX. 611 

reverse is the case. More or less tumefaction of the soft parts is observed, 
and sometimes a subcutaneons emphysema. The trauma vill rupture 
some of the blood-vessels, so that the patient begins to raise frothy blood- 
tinged mucus and has dyspnoea. The voice is impaired and cough is 
present with painful swallowing. 

Diagnosis.— This is made by the presence of the foregoing symptoms, 
while palpation generally reveals crepitus. Emphysema will give a 
peculiar crackling feel. Corresponding to the displacement of the carti- 
lages, there will be a distortion of the laryngeal image. 

Frognosis. — This depends on the amount, and especially the site, of 
the injury. It is evident that an injury comminuting the cricoid cartilage 
is attended by greater danger than one that simply cracks the thyroid. 
Quoting again from Durham's figures, it was foimd that out of the sixty- 
two cases there were twelve recoveries, in six of which the thyroid alone 
was affected, in two the thyroid and hyoid bone were involved, while in 
the remainder the exact seat of injury is not mentioned. Possible com- 
plications are supi)uration and pneumonia. 

Treatment. — The patient should at once be put to bed with the shoul- 
ders slightly elevated, ice-bags or. better, the Leiter ice-coil should be 
applied, and, if there be much contusion of the soft parts, leeches may 
be used with advantage. An endeavor should be made to mould the 
parts very gently into a normal contour, using, if necessary, adhesive strap- 
ping for purposes of retention. All food by the mouth must be interdicted 
and rectal enemata given. The symptom to be especially watched for is 
dyspnoea, and if this becomes threatening, tracheotomy may be necessary 
or an intubation-tube may be inserted. The latter has the advantage not 
only of supplying air, but serves as a splint around which the i)arts may 
heal. For this purpose a tube of a conical shape may be employed. 
Eesulting cicatrices must be dealt with according to the requirements 
of each individual case. 

Occasionally, apart from traumatic cases, patients may be seen in 
whom there is a luxation of the inferior horn of the thj'roid cartilage 
forward from its articulation from the cricoid. It occurs during a deep 
insi)iration, or more frequently in yawning, especially when the latter act 
is done in the recumbent position, and is therefore incomplete. It may 
happen on either side, recur frequently, then not again for a long time. 
Generally the pain from it is intense, though the condition is not attended 
by danger. Examination will show at the site of pain, on the inner side 
of the sternomastoid muscle, a slight prominence deeply situated at the 
level of the lower border of the thyroid cartilage. Downward and back- 
ward pressure will reduce it with a distinct noise, as may also a few 
efforts at swallowing. The predisposing cause is probably a loose capsule 
of the joint ; the exciting causes are the contractions of the sternothyroid 
and cricothyroid muscles, the movements of the larynx being restrained 
by its attachment to the hyoid bone. 



CHAPTEE XIY. 

CHRONIC INFLAIMMATIONS OF THE LAEYNX. 

Chronic Cataeehal Laryngitis. — The laryngeal mucosa may be 
the seat of a simi)le chronic catarrhal inflammation involving the entire 
lining or limited to certain localities. 

Etiology. — This condition is set up by a great variety of affections. First 
of all may be mentioned abnormal states of the upper air-passages, which 
undoubtedly cause the majority of cases coming under observation. Par- 
ticularly to be remembered in this connection are the common forms of 
rhinitis, both atrophic and hypertrophic, deviations of the septum nasi, 
chronic nasopharyngitis, enlarged tonsils, etc. All of these lesions inter- 
fere more or less with the proper functions of nasal and nasoxDharyngeal 
respiration, which are to warm, moisten, and purify the inspired air, and 
it can easily be understood how a vitiated air constantly passing through 
the larynx will gradually lead to chronic changes of a catarrhal type. An- 
other cause is the constant inhalation of irritant substances, the most 
common being dust incident to various occupations. Concerning the 
effect of alcoliol and tobacco in this direction, some extravagant state- 
ments have been made. Their excessive use is of course liable to set up 
chronic laryngitis, but this is because of previous involvement of other 
tissues higher up in the respiratory tract. In the vast majority of cases 
their moderate use does not seem to harm the larynx. It is difficult to 
obtain exact data on such points, for many cases of chronic laryngitis do 
not come under observation at all. A moderate degree of the morbid 
process is not incompatible with the proper exercise of the vocal organs 
in the ordinary requirements of life. It is only the professional voice- 
users to whom the question becomes a vital one. 

Another class of patients who suffer from this form of throat disease 
is composed of those whose business requires them to make unusual 
vocal exertions under unfavorable circumstances. While si^eaking in 
the open air according to well -recognized oratorical methods is a valu- 
able means of strengthening the voice, its constant use hour after hour 
in the open air, as in certain occupations^ or to an immoderate extent, 
as in the case of a political speaker addressing large audiences, is at- 
tended by most harmful results. Finally, there is the large class of 
voice-users, such as singers, clergymen, actors, etc., who work under 
fairly favorable conditions, but who, as a result of wrong vocal methods 
or improper manner of breathing while actively engaged in their calling, 
constantly strain the delicate structures of the larynx, and so set up 
chronic catarrhal changes, these latter exciting causes existing in addition 
612 



CHRONIC IXFLAM]MATIONS OF THE LARYNX. 613 

to a possible abnormal condition of the passages higher up. There is no 
doubt that certain chronic visceral diseases exert an unfavorable effect 
upon the larynx, as do also various diatheses. TThile the importance of 
this class of causes may have been exaggerated, it is not to be over- 
looked. Gastrohepatic disorders are found in some sufferers from chronic 
laryngitis who quickly recover as soon as the offending tract is put in 
proper order. So also in the gouty and rheumatic poisons are found 
agents which may localize their action on the larynx. 

Pathology. — Whatever may be the exciting cause of the disease^ the 
results are eventually the same. The blood-vessels become permanently 
dilated, and the various changes normally going on at the surface and 
in the substance of the mucosa assume a hyperactivity. There are in- 
creased cell formation and desquamation and an increase of secretion. 
In the mildest cases very few changes are evident, the membrane being 
nearly dry from deficient secretion ; this is more apt to occur when an 
atrophic condition of the rhinopharynx is the primary exciting factor. 
This dryness sets up an abnormal sensitiveness of the surface, to which 
are due the symptoms observed. If the case runs a long course there 
occurs later a thickening of the entire mucosa from the cell-deposit of 
connective tissue. This may produce either a uniform thickening or the 
surface of the mucosa may be irregular. The tubular glands and lym- 
phatic nodes share in the iDrocess, and thus there may be a granular 
api)earance of the membrane, — the larj^ngitis granulosa of some writers, — 
but there is no need to make a separate disease of this particular form. 
This later condition is essentiall}^ one of hyperplasia, and is more in 
evidence in the ventricular bands and arytenoid commissure. Changes 
in the vocal cords themselves consist mainly in increased vascularity. 
The activit}^ of cell proliferation at the surface of the mucosa may lead 
to small erosions, which are recognized by the absence of that peculiar 
smooth, glossy appearance which normal cords covered with normal 
mucus j)resent. These are always superficial, and heal readily. 

A subvariety of chronic laryngitis is that known as pachydermia 
of the larynx. It consists of a thickening of the superficial epithelium 
and of the deeper parts of the mucosa, which i^resents itself in the form 
of elongated projections from the general surface. It is most fr-equently 
seen in the i)OSterior commissure and the portion of the glottis between 
the arytenoids. It does not appear to have any relation to a special 
causation or diathesis. Varicosities of the small veins coursing over the 
ventricular bands are occasionally found. 

Si/iiqytoms. — The most obvious symptom is a loss of clearness of the 
voice. Under ordinary conditions of life- this may for a long time 
scarcely be noticed, but when any unusual or iDrolonged strain is put on 
the voice it is soon perceived. This huskiness will often improve for a 
while after taking food, or the voice may be clear for some hours in the 
morning, but gradually become hoarse towards night. If the sufferer be 



614 DISEASES OF THE LARYK^X, 

a professional voice-user there may be no apparent hoarseness at first, 
but the range becomes diminished, the voice is less controlled, and be- 
comes easily tired out. While there is no distinct cough, there is a fre- 
quent desire to clear the throat of the tenacious mucus which is apt to 
collect on the sensitive j)arts. Bosworth considers the existence of a true 
cough as evidence that the catarrhal process has passed beyond the limits 
of the larynx proper and has aifected the trachea. The affection is not 
a painful one, except in so far as there may be fatigue after vocal exer- 
tion. There is apt to be more or less dyssesthesia in the larynx, espe- 
cially a feeling as if the throat were being forcibly compressed. 

Diagnosis. — This can usually be made by the rational history of the 
disease. In examining the larynx one finds a change in the color of the 
mucosa, which over the arytenoid commissure and ventricular bands is 
of a deep reddish hue and slightly swollen. A moderate quantity of 
thick, grayish mucus may be found irregularly distribute^ over the 
parts. While the changes just mentioned may have a patchy distribu- 
tion, a condition of this nature strictly localized to one side should 
excite suspicion of a malady far more serious than mere catarrh. It 
generally signifies commencing infiltration, possibly from some peculiar 
diathesis, as tuberculosis, or perhaps more often from malignant deposit. 
Such cases should be most carefully watched, and all therapeutic measures 
employed with reference to the possible nature of the condition. Under 
such circumstances, also, the condition of the adjacent lymph-nodes 
should be carefully determined. The true cords are apt to appear some- 
what grayish in contrast with the reddened ventricular bands above them. 
They may be slightly thickened and their edges jDresent epithelial irregu- 
larities. The thickening of the mucosa prevents their proper approxi- 
mation and causes imjDcrfect tone formation. Moreover, as the result 
of the catarrhal state, various muscles become more or less paretic, no- 
tably the thyro-arytenoid, and thus ensue a lack of tension, a husky 
voice, and an elliptical appearance of the glottis. Of course, in making 
a diagnosis one must exclude the possibility of a tumor, an exudation, 
or a foreign body, a^j one of which may cause merely a hoarseness, 
without any additional change for a long time. Little, if any, danger 
exists that the condition now under discussion may lead to tuberculosis, 
or even i^redispose thereto, unless actual erosions are present. As the 
knowledge of the exact nature of tuberculosis has increased, it has been 
shown that the process is quite different from that of simple catarrh, 
and that the latter does not predispose to the former. Concerning 
catarrh in its relation to possible tumor formation, it may be said that 
it affords a favorable soil for the development of benign but not of 
malignant growths. 

Frognosis. — This depends somewhat upon the cause in each individual 
case, and also upon the possibility of removing it. If this can be efl*ected 
there is no logical reason why the disease should not be cured. It ought 



CHRONIC IXFLAMMATIOXS OF THE LARYXX. 615 

not to be looked upon as an incurable malady, though it is freely con- 
ceded that treatment may be required for a long time, demanding great 
patience on the part of the physician and great fidelity on the part of 
the patient. 

Treatment. — This should commence with the correction of all vicious 
habits of life and the relinquishment of all irritant ingesta, either of food 
or drink. During the stage of active treatment it is well to forbid tobacco, 
though its after-use in moderation may be permitted. The next step is 
to place the upper air-passages in good condition. Ehinitis must be 
treated, sei^ta straightened, and lymj^hoid deposits in the i^haryngeal 
vault or between the faucial pillars removed. Attention must also be 
IDaid to the lingual tonsil, as in many women at the middle period of life 
this structure is at fault and may affect the larynx. Eelief of the fore- 
going conditions is frequently followed by the disapi:)earance of all laryn- 
geal symptoms without any special attention to the larynx. Gener- 
ally, however, in a case of any duration, topical treatment of the latter 
will be necessary, and its employment may in any case hasten a cure. 
For local use an atomized spray of mild solutions is most advisable. The 
time-honored remedy is silver nitrate, not more than ten grains to the 
ounce. The tongue is held, and the tip of the si^raj-tube directed over 
the top of the epiglottis. Then, with the patient uttering a note of high 
pitch, the spray is driven into the larynx. If it be desired to reach the 
parts below, the spray is given during a deep inspiration. Other solu- 
tions available are zinc sulphate, ten grains to the ounce, copper sul- 
phate, somewhat weaker, and alumnol, fifteen grains to the ounce. Benefit 
is sometimes obtained by changing from one of these solutions to another 
from time to time. Internal medication may be of some subjective 
benefit to the patient, as by means of exi^ectorants, such as the muriate 
of ammonia and weak preparations of antimony, the secretion may to 
some extent be liquefied, and so conduce to its easy removal. AVhen 
the condition spoken of above as pachydermia su]3ervenes, it maj' be 
necessary to use solutions sufficiently strong to destroy the epithelial 
overgrowth. For this purpose zinc chloride, forty grains to the ounce, 
will answer. A more definite procedure is to use some acid, such as 
chromic or trichloracetic acid, which can be fused on a flat probe. This 
enables one to confine the application to any given spot, and is fi^ee 
from the possible danger of invading other parts. When there is a 
general relaxation of the cords, api^lication of a solution of equal parts 
of muriated iron and glycerin on a soft cotton brush will often re- 
establish the normal condition. Inhalations from steam atomizers are 
of little service in chronic laryngitis. The absolute necessitj' of rest of 
the vocal organs in singers and speakers is too apparent to call for more 
than mention. 

Atrophic Laryngitis. — This name is given to a condition of the 
larynx in which there is a crust formation and deficiency of moisture. 



616 DISEASES OF THE LARYNX. 

The crusts adhere to the lining membrane of the larynx, much as do 
ozgenatous crusts In the nose. The disease is known also as laryngitis 
sicca. 

Etiology. — According to most authors, the condition is practically 
never found without a similar condition higher up. Shurly states that 
he has seen cases confined to the larynx in girls who were taking music 
lessons. Generally the nose is atrophic, and sometimes the nasopharynx 
also. The process in the larynx cannot be looked upon as one of mere 
extension, for there seems to be some inherent property in the laryngeal 
mucosa which leads to an abnormal dryness. Given this predisposition, 
it is easy to see how the local state will be aggravated by the inhala- 
tion of a vitiated air due to lesions in the parts above. The late J. C. 
MulhalP described what he called '^laryngitis hiemalis," a subacute 
catarrhal laryngitis in which the secretions were adhesive from the 
beginning. In Mulhall's view, the peculiarity of the condition was that 
the cases were seen only during the winter, and were distinctly without 
involvement of either nose or nasopharjmx. 

Pathology. — The changes are exactly analogous to those taking place 
in atrophic rhinitis, treated of in another section of this volume. 

Symjytoms. — During the day, when the laryngeal muscles are in fre- 
quent motion, crust formation is not so annoying, but at night the crusts 
tend to accumulate, so that on waking the patient finds his voice more 
or less impaired, and there may even be a partial dyspnoea from occlusion 
of the larynx. In addition, there is the natural desire to clear the 
throat, and, when this has been effected, the voice is again clear. The 
expulsion of the crusts may be accompanied by a little bleeding, and 
shallow erosions are left behind after their removal. They are of the 
same general appearance and odor as those seen under corresponding 
conditions in the nose. 

Diagnosis. — The expulsion of crusts will direct attention to the seat 
of the malady, and by means of the mirror others can easily be seen 
lying in the larynx. The posterior portions of the larynx, especially the 
commissure, are the more frequent seat of the disease when the latter is 
above the level of the true cords. Crust deposit, however, is often con- 
fined to the subglottic region. 

Treatment. — From what has been said as to causation, it is evident 
that the first thing to do is to put the nose and nasopharynx in good con- 
dition. This consists in remedying mechanical defects and in thorough, 
persistent cleanliness. The larynx may be cleansed by spraying with a 
weak Seller or Dobell solution, which loosens the crusts and allows of 
their easy expulsion. Then follows the use of some weak alterative solu- 
tion, or of menthol, which can be dissolved in a bland hydrocarbon such 
as albolene. Internal remedies do not seem to be of much service. 

^ Trans. Amer. Laryngol. Assoc, 1893, p. 51. 



CHRONIC IXFLAMMATIOXS OF THE LARYXX. 617 

Potassium iodide and muriate of ammonia have been given, with the 
object of increasing secretion. Better results seem to have followed the 
muriate of pilocar^^ine. 

XoDULAE Laryxgitis, — By this term is meant an exaggeration of 
the epithelial thickening which is frequently observed at the junction of 
the anterior with the middle third of the true cords. The disease is also 
called trachoma of the cords, singers' nodules, and chorditis tuberosa. 

Etiology. — This condition is generally, but not always, confined to 
singers, and is the result either of overstrain or of faulty vocal methods. 
Moure has described a series of cases occurring in children from seven to 
ten years of age, ^ but even in them he attributes the disorder to the vocal 
excesses to which modern school methods often subject this class of 
patients. Botej" ^ finds the condition more common in sopranos, less so 
in mezzo voices, infrequent in barytones, and rare in basses. He describes 
what may be styled a '^prenodular stage," calling attention to the fact 
that in the head-notes of soi^ranos and mezzos only the anterior three- 
quarters of the cords vibrate. The higher the note the less, of course, 
the length of the vibrating medium, which with the very highest notes 
is reduced to a length of not more than eight or nine millimetres ; hence 
there is an immense quantity of energj- expended, during which the junc- 
tion of the anterior third with the rest of the cord is the central i)oint of 
an intense vibratory oscillation, the greatest amplitude of which is con- 
fined to a space of not over three millimetres. This is the exact seat of 
election of the singers' node. 

Pailiology. — From the foregoing explanation it is easj' to see how 
voice-use during any condition of inflammation or swelling will cause 
the oj^posing points on the two cords to come in contact one with the 
other, and from the friction thereby i^roduced set up irritation and 
epithelial i^roliferation. Another theory as to the i)roduction of these 
nodules is the outgrowth of the discovery by B. Frankel, some ten 
years ago, of a gland situated in the cord, the duct of which oj)ens in 
the membranous i)ortion of the cord directly under its edge. Eepeated 
histological examinations by various authorities have proA'ed the ex- 
istence of this minute structure, and secretion has been seen to issue from 
it during phonation ; hence, if from any reason the mouth of the duct 
becomes stop]3ed, there may be a swelling of the gland or a dilatation of 
the duct, forming a retention cyst, which, however, will often disappear 
under rest. Eosenberg ^ has seen a broadening and thickening of the cord 
in the entire region of the i^ars libera, being es]3ecially noticeable at the 
edge. This condition maj' prevent perfect apposition with the oppo- 
site cord, and later connective-tissue formation may take place. The 



^ Rev. de Laryngol, 1896, vol. xvii. p. 145. 

2 Ann. des 3Ial. de 1' Oreille, 1899, vol. xxv. p. 249. 

^ Laryngoscope, 1899, vol. \T.i. p. 219. 



618 DISEASES OF THE LARYNX. 

friction of a nodule at a given site on the cord frequently causes the for- 
mation of one at the symmetrical point on the opposite cord. 

Symptoms. — These consist solely of defective voice formation, there 
being no pain, cough, nor dyspnoea. The voice is husky, weak, and 
possibly aphonic, from imperfect api)roximation of the cords ; its vari- 
ous finer qualities are lost, and its tone becomes uncertain. Singers, 
therefore, become nervous and apprehensive, and the condition is thus 
aggravated. 

Diagnosis. — The mirror will easily reveal the site and nature of the 
difficulty. If it has persisted long, there may be some evidences of chronic 
laryngitis and imperfect tension of the cord, as mentioned under that 
condition. 

Treatment. — While these nodules may persist for years without ap- 
parent increase in size, their removal is needful in those whose voices 
furnish their means of livelihood. Eest of the vocal organs is absolutely 
necessarj^ This will doubtless cure some cases of recent formation and 
due to glandular occlusion. It is this class of cases which is benefited 
by various vocal exercises following the initial rest. For the removal 
of a nodule, strong solutions of silver nitrate of a drachm to the ounce 
may be applied to the site, localized by means of a fine applicator. 
Perhaps fused chromic acid allows the caustic to be more definitely 
applied. The galvano- cautery point has been used for this purpose. 
Cutting forceps are recommended by some for the actual avulsion of the 
nodules. Botey records a recurrence of fifty per cent, when the galvano- 
cautery was used, but only twenty per cent, when the cutting forceps 
were employed. 

VASCULAR ABNORMALITIES. 

Ancemia. — Anaemia of the larynx cannot be considered as a separate 
malady, being merely one expression of the general anaemia attendant on 
constitutional dyscrasise. At other times it is of special importance in 
its relation to a possible lurking development of tuberculosis. Cases 
presenting distinct anaemia of the laryngeal mucosa, especially if asso- 
ciated with chronic laryngitis or aphonia, should be subjected to the most 
thorough general examination, the sputa examined for bacilli, and the 
case kept under careful observation. 

Hyper cemia. — This condition is the forerunner of many inflammatory 
states, some of which have already been considered, while others, as 
syphilis and tubercle, are treated of later on. As has been stated, the 
larynges of many vocalists and of those engaged in certain occupations 
are in a state of continual hyperaemia without being in one of actual 
inflammation. 

Laryngeal Hemorrhage. — Apart from those cases in which bleeding is 
merely an accompaniment of some specific process, as a foreign body, 
ulcerations, etc., there are cases in which the larynx is the source of 



CHRONIC INFLAMMATIONS OF THE LAEYNX. 619 

Lemorrliage. This may be a feature of an acute inflammation, or of some 
chronic visceral disease like that of the liver or heart, or due to direct blood 
dyscrasise, including hgemoi)hilia. The various forms of anaemia may 
manifest themselves in this way. A condition of chronic inflammation 
may predisi^ose to this accident, the exciting factor being severe local or 
general overexertion. 

Patlwlogy. — This is suggested by the definition of the condition. There 
may be either an actual rux^ture of vessel-walls or a diapedesis. Hem- 
orrhage may be concealed, the blood collecting under the mucosa and 
forming a hcematoma or a submucous infiltration without any actual leak- 
age. This form ma^^ result from vocal strain. 

Where the blood escapes from the vessels there may be a very small 
area of leakage, even a single point. More often this site is located on 
either the ventricular bands or true cords. In many instances it is not 
possible to find any esi^ecial exciting cause, and it must be concluded 
that there is some alteration in the integrity of the vessel-walls, so that 
forces which under ordinary circumstances would not be sufficiently 
powerful to exert any influence are able to produce the accident. 

Symptoms. — These vary according to the nature of the bleeding. If 
the hemorrhage be submucous there will be evidences of laryngeal 
irritation, together with more or less imx^airment of vocal function. 
I^othing about the subjective symj)toms, however, suggests the exact nature 
of the cause. If the bleeding be actually an escape of blood to the surface, 
there occurs the familiar haemoptj'sis. The blood generally comes up 
clear or mixed with mucus, and is scanty in quantity. A clot may so 
form in the larynx as i:)artially to occlude the glottis and cause dyspnoea, 
but this is rare. 

Under these circumstances it will at once be appreciated that the 
immediate task is definitely to locate the source of the hemorrhage. This 
is not always easy from mere inspection, because the constant movements 
of the throat will spread the blood irregularl}' around the region, what- 
ever may be its source. Moreover, blood may trickle down from x>arts 
above and appear in the larynx ; hence the examination should include 
the nose, and esi)ecially the nasopharynx and region of the lingual 
tonsil. In an ordinary pulmonary hemorrhage, if the throat be not too 
irritable to allow satisfactory examination, the irregular blood-clots can 
generallj* be seen on the sides of the trachea, while this is not ordinarily 
the case in laryngeal hemorrhage, in which the blood remains confined 
to the larynx. Careful inspection of the larynx will generally reveal 
the source of the bleeding, and examination of the lungs may assist 
in the diagnosis. In concealed hemorrhage the sudden onset and the 
appearance of a reddish swelling at some point on the laryngeal wall 
will clear up any doubt. Finally, it may be that in rare cases the loca- 
tion of the haematoma is such that it is not plainly visible, and the pos- 
sibility of this fact should be borne in mind in endeavoring to account 



620 DISEASES OF THE LARYNX. 

for a sudden case of dyspnoea, and those rare cases due to menstrual 
disorders must not be forgotten. 

Prognosis. — This is of importance merely with reference to the sig- 
nificance of the exciting cause, for laryngeal hemorrhage is never fatal. 

Treatment. — This should be directed to the improvement of the blood 
condition and the visceral state which may underlie the hemorrhage. If 
the hsematoma be large, the general rule of opening it and turning out the 
clot may be followed ; if it be small, it may be allowed to absorb. Local 
rest must be enjoined, and ice-pellets should be freely used, together with 
the coil over the larynx if the bleeding be persistent. A mild diet 
should be observed, one free from all highly seasoned and irritant foods, 
and for a day or two one which includes cold food. The action of in- 
ternal remedies or hsemostatic agents on the blood-flow, such as ergot, 
gallic and tannic acids, is very unreliable. Probably the best effect 
can be obtained from a full dose of morphine, with atropine given 
hyjDodermically. 

Locally, one may use a mild astringent spray, as previously described. 
The drug combinations for this purpose are iron, alum, or the aceto- 
tartrate of alum, ten grains to the ounce, or the solution of iron persul- 
phate, not over ten minims to the ounce. The use of tannin in these cases 
is not to be relied on, as recent experiments have shown that this agent 
precipitates the albumin of a part, and so forms a protective layer of 
tannate of albumin ; hence the local api3lication of tannin to bleeding 
vessels does not cause their contraction, but often their relaxation. In 
cases in which hepatic disease is present, the unloading of the portal 
system with a mercurial followed by a saline purge will at once suggest 
itself. A blister over the liver is often of service. 

DISEASES OF THE EPIGLOTTIS. 

While this cartilage is generally considered one of the laryngeal rather 
than pharyngeal structures, and shares in a general way in the affections 
of the former, it may be the seat of certain processes which entitle it to 
separate consideration. 

Concerning its function there is still some doubt. It helps to prevent 
entrance of food into the larynx during the act of swallowing, but this 
lid-like action is not indispensable to life, for it may be removed either 
for purposes of experiment or by processes of disease without any great 
impairment of deglutition. It has been looked upon as a ^^sounding- 
board" for reflecting the vocal, sound- wave to the pharynx, where it is in 
part articulated. If it be destroyed the voice becomes less distinct, and if 
its edges be irregular and jagged the voice may be distinctly rough and 
harsh. 

The healthy epiglottis may assume various shapes, all of which are 
consistent with perfect function. It may be curved, angular, pendu- 
lous, or folded, and its edges may be smooth, serrated, or crenated. 



CHROXIC IXFLAMMATIOXS OF THE LARYXX. 621 

The under or laryngeal is always of a redder hue than the npi^er or lin- 
gual surface. 

It is unusual for the epiglottis to be the seat of primary affections, it 
being generally secondarily involved, as in lupus, tuberculosis, and 
syphilis, in which it presents the lesions of these respective processes. 
So far as concerns its mucous covering, it shares in the various catarrhal 
conditions of the pharynx and larj^nx. Its edges are sometimes com- 
pressed in enlargement of the lingual tonsil, forming the so-called ^^in- 
carceration of the epiglottis." The cartilage frequently responds to this 
irritation by growing larger, but resumes its normal size when the source 
of irritation is removed. Specific lesions of the epiglottis are considered 
under their respective headings, but certain independent conditions are 
occasionally found which may here be mentioned. 

During the past few 3 ears various writers have reported a condition 
called by them ^'angina epiglottidea anterior," a term proposed b}^ 
Michel in 1878. By this is signified an oedematous condition confined to 
the cartilage and usually to its anterior surface. The true cords may be 
reddened, but, as a rule, the larynx is not much involved, it being rare to 
find nuj general swelling of the entire laryngeal mucosa. It is perhaps 
an extreme view to regard this as a separate affection, for, so far as causa- 
tion is concerned, it may be nothing more than one of the many varieties 
of oedema of the larynx. 

Primary chondritis leading to ulceration and abscess is very rare, but 
that it does occasionally occur cannot be doubted. 

Simple Exlaegemext of the Epiglottis. — This is a pure hyj)er- 
chondrosis, with more or less thickening of the mucosa covering the 
organ. The causes are in general the same as those which lead to pharyn- 
geal catarrhs. 

Symptoms. — It may be difficult to separate the symptoms of an en- 
larged ei)iglottis from those due to associated lesions, such as an enlarged 
lingual tonsil or a varicose condition of the lingual veins. There are 
found here the same round of painful pharyngeal sensations, irritative 
cough, involuntary swallowing, sensation as of a foreign body, vocal im- 
pairment, and irritability of the digestive organs. During exacerbations 
of the local inflammation of the overlying mucosa, painful swallowing is 
the most noticeable feature. The enlargement may be vertical or hori- 
zontal. The change in the organ is cpiite independent of changes in the 
larynx, and does not seem to depend on those causes which affect catarrhal 
states in general. The irritation at the bottom of this tumefaction may 
be the enlarged lingual tonsil, or j)0ssibly some congenital peculiarity of 
the eiDiglottis either in size or shape may lead to the i)rimal irritation. 
Merkel showed thirty-five years ago that under normal conditions the 
margin of the epiglottis, when the organ covered the larynx during deg- 
lutition, escaped the posterior pharyngeal wall by a quarter of an inch. 
Frequently the least exciting cause, such as talking, singing, eating, 



622 DISEASES OF THE EARYNX. 

change of temperature or of posture, going out into the cold air, etc.^ 
may set up an attack of coughing, or render the voice temporarily in- 
competent for use. 

Treatment. — All sources of irritation should be removed and an anti- 
catarrhal regimen established. Such measures, if faithfully carried out, 
will often permanently relieve the milder cases^ while there are others 
which they fail to help. Astringent applications alone are of little use. 
Cocaine followed by an oily spray will relieve the symptoms, but its con- 
tinued use is objectionable. The employment of the galvano-cautery to 
reduce the size of the cartilage is liable to be followed by severe reaction. 
Eice advises the trimming off of a strip about one-eighth of an inch broad 
from the margins of the cartilage where they impinge on the lateral phar- 
yngeal walls, using for this purpose long, curved-handled scissors. Eeac- 
tion is only moderate and hemorrhage is not excessive. Brown suggests 
as a suitable instrument a rectangular epiglottome in which the teeth 
merely transfix the cartilage without drawing it through the ring. In 
this way the portion to be removed is under the full control of the 
operator. 

CHONDRITIS AND PEEICHONDRITIS OF THE LARYNGEAL CARTILAGES. 

The occurrence of a primary chondritis is denied by most writers, 
who look upon the condition as secondary to involvement of the peri- 
chondrium. The gradual ossification which the cartilages undergo from 
advancing years can hardly be regarded as a disease. The cases due to 
tubercle and to malignant disease are generally masked by the composite 
of these symptoms, and rarely assume the type of severity that is seen in 
other diseases. 

Etiology. — Many of these cases are caused by exposure to cold and wet, 
others by various kinds of trauma, injuries inflicted during surgical o^Dcr- 
ations, erysipelas, diphtheria, pneumonia, any of the exanthemata, and 
particularly those continued fevers and diathetic states which confine 
patients long to their beds. This latter variety has been ascribed to the 
pressure of the cricoid against the vertebrae in the recumbent position. 
Lennox Browne has described what was believed to be a condition of cal- 
careous degeneration due to a gouty deposit in the epiglottis, with symp- 
toms of enlargement of the right crico-arytenoid articulation, in a man of 
sixty-two, of confirmed gouty habit. He adds that in almost all peri- 
chondrial inflammations not the result of traumatism the disease com- 
mences in the neighborhood of this joint. Birkett,^ of Montreal, has seen 
one case of disease in this locality which he believed to be the result 
of a local gonorrhoeal rheumatism. Other cases due to ordinary rheu- 
matism have been reported by several observers. In many instances the 

^ Trans. Amer. Laryngol. Assoc, 1896, p. 185. 



CHRONIC INFLAMMATIONS OF THE LARYNX, 



623 



morbid process may begin in the perilaryngeal soft tissues. Bresgen ^ 
finds a cause in overexertion of the vocal organs. 

Pathology. — The condition begins with an increased blood-supply, fol- 
lowed by increased cell- production. Swelling results, followed by pus 
formation and the consequent separation of the perichondrium from the 
underlying cartilage. The latter becomes superficially eroded and in 
many places softened. Any or all of the laryngeal cartilages may be 
affected, though it is most usually confined to one. ' ' Most authors ap- 
pear to consider that caries is a necessary sequence of perichondria! 
inflammation ; but this is certainly incorrect, for in not a few cases the 
inflammation terminates in resolution with more or less thickening and 
functional impairment, but without caries or separation of any j)ortion 
of the cartilages" (Lennox Browne). It is possible, however, for por- 
tions of cartilage to become separated and then expectorated. 

Fig. 252. 




C~' 




A. Perichondritis cricoidea. (Rosen- 
thal.) The abscess projects beyond and 
beneath the left vocal band. 



B. Perichondritis arj-tsenoidea. (Ro- 
senthal.) The left arycartilage has been 
separated and expectorated. 



Symptoms. — The general symptoms are those of an acute inflammation, 
with chills and fever, general malaise, etc. Local symptoms dei^end 
somewhat on the special cartilage involved. There is a sense of fulness 
in the part, with tenderness on pressure, but pain is not a x^rominent 
feature in either the primary or secondary form of the disease. Cricoid 
disease especially causes dyspnoea, loss of voice, and possibly dysphagia if 
the part involved be posterior, thus affecting the oesophagus (Fig. 252, A). 
Thyroid involvement causes interference with the voice and with respi- 
ration. Cases are on record in which the pus has discharged through a 
fistulous opening in the neck. If the lesion be bilateral, phonation be- 
comes impossible. If the inner surface of the cartilage be affected, 
dyspnoea becomes a i)rominent, and in cases of bilateral involvement 
an alarming, feature. If the arytenoid be affected, a swelling forms which 
interferes with both swallowing and breathing (Fig. 252, B). It is this 
form which causes the ankylosis of the crico-arytenoid joint, above noted. 
This, of course, affects the voice. 



Krank. des Kehlkopfs, 1891, S. 381. 



624 DISEASES OF THE EARYNX. 

Diagnosis. — This is a matter of some difficult}^, even after a careful 
observation of the case. Frequent examinations will generally enable 
the observer to finally localize the seat of the disease. Initial symptoms 
may be simulated by a croupous laryngitis, but the type of general symp- 
toms in the latter is rather more severe, and the exudation, if present, can 
usually be detected. Thyroid and arytenoid cases are usually diagnosed 
without much difficulty, while cricoid cases are extremely x)uzzling. 
The swelling will be seen without difficulty, but it may at times be 
Impossible to say positively from which cartilage it springs. Fortunately, 
this does not affect the treatment, which is the same no matter where 
the focus of disease may be. 

Frognosis. — Immediate danger to life is small. The cases run a pro- 
tracted course, and there is ample time to prepare for emergencies. The 
eventual outcome is quite another matter, so far as concerns the retention 
of perfect laryngeal function. Cases affecting all the cartilages are, as a 
rule, fatal in a few months, but these are more often due to some under- 
lying dyscrasia, which is the real fundamental cause of the fatal result. 

Treatment. — This should be begun with the general measures appli- 
cable to inflammatory conditions, and the use of the ice-coil, leeches, or 
cups externally. Internally, ice-i)ellets should be freely used, and, if 
necessary, opiates may be given to quiet local distress. Cocaine spray, 
or, better in these cases, eucaine in, say, ten per cent, solution, may be 
employed. Potassium iodide is the only internal remedy which seems 
to be of any service. It should be begun in moderate doses, which 
should be continued for some time after the subsidence of acute symp- 
toms, care being taken that it does not derange the digestive organs. A 
good plan is to slowly Increase and then diminish the dose. If the car- 
tilage dies, the progress of the sequestrum must be watched, for the 
sooner it can be removed the less liability there is to deformity. Various 
surgical procedures may be adopted, among which may be named dila- 
tation in the later stages. Dyspnoea in the course of the disease may 
require tracheotomy or laryngotomy. The use of absorbent ointments 
applied externally does not seem to be of much benefit. 



CHAPTEE XY. 

TUBERCULOSIS OF THE LAEYXX. 

There is no longer auy doubt that tuberculosis may primarily affect 
the larynxj though many of the cases placed iu this category do not i)re- 
sent sufficient evidence to exclude the possibility of the existence of some 
other local deposit to which the laryngeal affection is secondary. Au- 
tojisies show various foci of the disease, so that it is not possible to say 
just where it begins. So for as the writer knows, no case of laryngeal 
tuberculosis has ever progressed to a fatal termination without evidence 
of invasion of other structures, though autopsies have sometimes shown 
the larynx invaded, but the lungs free. Most cases under this heading 
are secondary to tuberculous deposits, especially in the lower air-tract, 
or at least coexist with them, while other organs, such as the pharynx, 
palate, and nose, show by contiguity, and the liver, spleen, kidneys, 
and genito-ui-inar^^ tract by metastasis, additional deposits. The exist- 
ence of laryngeal lesions in connection with pulmonary tuberculosis 
was long recognized, without, however, any accurate idea of their true 
nature. 

The frequency of the association of laryngeal with pulmonary tuber- 
culosis has been the subject of much statistical research. Figures are 
variously given by diffei-ent writers, but in a general way it may be said 
that while probably one-third of all pulmonary cases in-esent laryngeal 
deposits, in only about one-eighth to one-seventh do the latter develop 
into active lesions leading to a i^rogressive destruction of the larjmx. 

Etiology. — It is now generally agreed that the cause of tuberculosis 
is the invasion of the tissues by the bacillus of Koch ; but there must 
be, in addition, a peculiar receiDtivity of the tissues, which may result 
from any one of a large group of foctors, including heredity. This bacillus 
is responsible for about one-seventh of all deaths from all causes com- 
bined. Autoi)sy records at any of our large hospitals show that every 
third or fourth cadaver reveals (regardless of the exact cause of death) 
evidence of healed or active tubercular disease, generally in the lungs. 
The enormous prevalence of this particular micro-organism is at once 
apparent, and it can hardly be doubted that every one receives, at some 
time or other, a dose of the tubercular poison, which, if his system offers 
the necessary receptivity, will result in an active outbreak of the disease. 
These observations apply especiallj^ to general infection, which localizes 
itself in the lungs more often than in any other organs. The most vulner- 
able portion of the pulmonary structure appears to be the posterior part 
of the apices, possibly as the result of the direct discharge of infected chyle 

40 625 



626 DISEASES OF THE LARYNX. 

into the vena cava, the poison having j)robably entered the system 
through the food^ or through moist germs swallowed or inhaled, or pos- 
sibly through the infection of the tonsillar tissues. 

In primary cases the infecting material may either find direct lodge- 
ment on the laryngeal mucosa, or may be brought thereto by vascular 
channels, probably the lymphatics. Korkunoff'^ believes that an im- 
mense majority of bacilli are carried from the pulmonary foci by the 
blood- and lymph-vessels into previously dilated subepithelial lymph- 
spaces of the mucosa, and that they penetrate the epithelium from without 
only in some of those exceptional cases in which there has occurred from 
other causes some solution of continuity which offers to the bacilli in the 
sputa a portal of entrance. It cannot be doubted, however, that bacteria 
do get through the epithelial cells, though in many instances they seem to 
be destroyed by phagocytosis. Eichard Lake ^ believes that many micro- 
cocci, ordinarily at rest on the surface of the epithelium, find their way 
during coughing attacks and during sleep into the interstices between the 
cells. Some are removed by phagocytosis ; others, by virtue of their over- 
whelming numbers, establish themselves, and by cell-destruction lead to 
the formation of small abscesses. These rupture, their bacterial contents 
being still non-tubercular ; but the abscess cavities increase in depth, and 
by the time the submucous tissue is reached infection by the tubercle 
bacillus occurs. It is certainly a striking fact that the most frequent site 
of inoculation corresponds with the most frequent site of erosions, both 
being the anterior aspect of the arytenoids and about the posterior 
insertion of the true cords. 

As to the increased likelihood of infection in a larynx previously the 
seat of catarrhal disease, it may be said that this exists mainly when the 
catarrhal process has led to erosions, probably rarely otherwise. Natu- 
rally an inflamed structure is more liable, in consequence of its tempo- 
rarily lowered vitality, to invasion by any deleterious agent than is one 
perfectly normal ; hence chronic catarrhal states of the mucosa of the 
larynx and adjacent structures can be regarded as definite predisposing 
causes. All depressing habits, such as alcoholic excess, over-use of voice, 
etc., may be included in the same category, but only through the antece^ 
dent stage of catarrhal inflammation leading to erosions. Syphilis may 
coexist with tuberculosis. Notwithstanding all these facts, it must be ad- 
mitted that, on account of what is called " tissue- resistance, " the larynx 
enjoys a remarkable immunity from tubercular deposit when one con- 
siders the assaults to which it is exj)Osed. The affection is more com- 
mon in men than in women. Young adults present by far the largest 
number of cases, but this is the age at which pulmonary tuberculosis is 
most common. Certain occupations, such as those attended by much 

1 Deut. Arch. f. Klin. Med., 1889, Bd. i. Heft 2. 

2 ADier. Jour. Med. Sci., April, 1895, p. 407. 



TUBERCULOSIS OF THE LARYNX. 



627 



Fig. 253. 



exposure to dust-laden air or by confinement in poorly ventilated work- 
ing-places, bring the system into a receptive condition. 

FatJioJogy — The alterations at tlie affected site resemble in a general 
way tubercular changes in other structures. Often there appears to be a 
stage of x)receding inflammation^ due to the indirect influence of the 
tubercular diathesis before the actual deposit of tubercle. The changes 
begin with a dilatation of the blood-vessels and lymph-channels, with 
some proliferation of the white blood-cells and of the lymph-cells which 
resemble them, an increase in the wandering cells of the connective 
tissue, and the mesh-work of the tissue becomes more or less oedematous. 
If the infection continues, or becomes more severe, there maj^ be a small- 
celled infiltration 5 but \i\) to this point resolution is possible, or fibrous 
changes may be set ui3, so that the process 
comes to an end. Ulceration is very un- 
common, and unless it occurs it is very dif- 
ficult, if not impossible, to find bacilli in 
the sputa. 

When actual tubercle is formed, those 
I)oints on the mucosa at which lymphoid 
tissue is abundant suffer especially. The 
deposit is formed in the membrane proi^er, 
and for a while the epithelium remains 
unchanged. The most frecxuent sites of 
invasion are the i^osterior commissure, 
mucosa of the arytenoid cartilage, ary- 
epiglottic folds, true cords, and epiglottis, 
glands seem to be esi^ecially vulnerable, 
structures are invaded, but the crico-arj^tenoid joint generally escapes 
actual deposit. After the process is fally developed there are found the 
ordinary tubercles, at first scattered, but later coalescing into masses visi- 
ble to the eye. They consist of j)ortions of granulation-tissue surround- 
ing giant or ei)ithelioid cells, and are in turn themselves surrounded by 
a zone of round- celled infiltration. The tubercle itself is non- vascular, so 
that there is an early tendencj" of the structure to break down, and at the 
same time the small arteries going to the invaded area become the seat 
of an obliterating endarteritis. As a result, there are a localized necrosis, 
a subepithelial erosion, and finally a penetration of the surface layer and 
the discharge of nodular contents, the cheesy softening thus leading to 
the formation of an ulcer. This is minute at first, but gradually coalesces 
with its fellows until a large area is affected. The tubercular deposit 
may at the same time work deej^er and extend to the cartilages. 

Microscox^ic siDecimens will show the XDresence of the tubercle bacilli, 
especially during the earlier stages of the cheesy softening, when they 
are, as Lennox Browne suggests, x^erhaps more easy of detection, owing 
to their greater selective affinity at this time for staining agents. When 




Tubercular intiltration of the larynx. 
(Grunwald.) 

The acini of the tubular 
Gradually all the laryngeal 



628 



DISEASES OF THE LARYKX. 



the process is not too extensive in area, nature endeavors to circumscribe 
it, and not infrequently succeeds, for one often sees tuberculosis arrested 
in the larynx, though the systemic deterioration from pulmonary or other 
tubercular lesions may steadily go on. The peritubercle tissue shows 
great vascular activity and a formation of fibro-connective tissue which 
is nature's barrier. In fact, this process suggests the proper method of 
cure, so far as local disease is concerned. Yiewing the process from a 
purely clinical stand-point, the first change from the normal is in the 
vascularization of the mucosa of the larynx. In the ordinary chronic 
form of the disease it becomes distinctly anaemic ; the mucosa of the 

entire throat may also be anaemic. 
This general pallor is most sus- 
picious, and should always lead to 
a most thorough examination of 
the chest, and the patient should 
be kept under close observation. 
Most cases, however, will show by 
the time they first come under ob- 
servation unmistakable evidences 
of infiltration with more or less 
swelling. As before stated, this 
most frequently appears in the in- 
terarytenoid space, but in many 
voice-users it first appears on the 
cords, rarely in the epiglottis. The 
result of this infiltration is to pre- 
vent free movement of the various 
muscles of i)fioiiation. Interary- 
tenoid de^DOsit naturally affects the 
adductors, while infiltration of the 
crico-arytenoid joint acts in a simi- 
lar way, though the joint generally 
escapes actual deposit. In some 
instances, where there is no actual 
obstacle to proper cordal action, 
the patient seems too weak to properly use the muscle, that in turn may 
sometimes suffer from actual tubercular deposit. Following this stage 
of infiltration, there ensues that of breaking down or ulceration. The 
peculiarities of the tubercular ulcer have been described when speaking 
of the localized process in the pharynx. It is shallow rather than deep, 
is covered with thick, ropy mucus, and no very marked boundary exists 
between the edges of the ulcer and the surrounding area (Fig. 256). 

Under the conditions named the vast majority of ulcerations are of a 
tubercular nature, but there are others which are simi)le erosions, due 
probably to irritation from sputa, and must not be looked upon as the 




Section through the right aryepiglottic lig- 
ament. (Rosenthal.) a, a, tubercle; h, mucous 
glands. 



TUBERCULOSIS OF THE LARYNX. 



629 



portals of the original infection. Succeeding the ulceration is the in- 
vasion of the cartilages, which, however, is not always evident on insi^ec- 
tion during life. Earely in proi)ortion to the whole number of cases is 
there any actual extrusion of cartilage, though occasionally a complete 
cartilage with carious surface has been expelled, esiDeciallj^ the arytenoid. 
If chondritis or j)erichondritis be set ux), there are seen the usual featui'cs 
of this condition. The exact nature of the disease is determined hj the 
association of the local process with the general tubercular state. Finally, 
there is a rare class of lesions, consisting of tumors, — tuberculomata, — 
which are of great interest from a histo-i^athological i^oint of view. The 

Fig. 255. 




Tuberculosis of the larynx. (Seifert and Kahn.) a, epithelial covering, thickened ; h, involutions 
of the same into the subepithelial connective tissue; c, cellular infiltration of the latter; d, tubercles 
with giant cells ; e, tubercles -with epithelioid cells ; /, dilated vein ; g, arterj\ 



growths appear as smooth, rounded tumoi^s, single or multiple, or some- 
times merely as papillary excrescences (Fig. 257). Examination shows 
them to consist of tubercular tissue generally containing the bacillus, but 
accompanied by only slight evidences of tubercular infection in the lungs 
or elsewhere, and at times by no such evidence. 

J. X. Mackenzie believes such growths to be ^'anatomically allied to 
granulation- tissue and a natural step towards cicatrization.'- ^Yart-like 
excrescences are frequently found in the interarytenoid tissue, and several 
writers attach great diagnostic value to their recognition. Browne 
dissents from this exclusive view, stating that they ''are quite as often 



630 DISEASES OF THE LARYNX. 

seen in connection witli syphilis or even in clironic laryngitis indepen- 
dently of any specific dyscrasia." Tuberculomata of the trachea have 
been described by Ariza and J. X. Mackenzie. 

Symjjtoms. — The most common initial symptom is impairment of vocal 
integrity. At first, speaking may be simply difficult without noticeable 
alteration of tone, and apparently due only to im^Dairment of thoracic ex- 
pulsive power. [N'othing abnormal is found on examination. Such slight 
symptoms are of significance with reference to tubercular disease only in 
connection with evidence of lesions elsewhere. Instances of eunuchoid 
voice have been reported by Castex ^ and others. If the local process has 
gone on to actual infiltration sufficient to prevent perfect approximation 
of the posterior ends of the cords, there are varying degrees of hoarse- 
ness corresponding in a general way to the extent of the lesion. Browne 

Fig. 256. Fig. 257. 




Tubercular infiltration and ulceration. (Grun- Diffuse tuberculous infiltration of the entire 

wald.) larynx, and tuberculous tumor formation. (Griin- 

wald.) 

calls attention to a vocal condition not generally described. ' ' This is 
found in the rapidity with which the voice changes in character during a 
short conversation from a gruff hoarseness to a high falsetto, which as 
quickly passes into a toneless whisper." This variation is doubtless due 
to lodgement and dislodgement of secretion and also to peripheral nerve 
irritation affecting the tension of the cords. Minor vocal changes are the 
same as in congestion from any cause, and the voice may show periods of 
freedom from any impairment. Another early symptom is cough, at first 
dry, and coming on in a jerky manner whenever the patient attempts 
to speak. At times it is like that of pertussis, followed or not by ex- 
pectoration and frequently by vomiting. This stage is often associated 
with intralaryngeal irritation as from a foreign body. Later, cough 

^ Compte rendu de la Soc. Fran, de Lar. , 1896. 



TUBEKCULOSIS OF THE LARYNX. 631 

becomes more pronounced and is accompanied by the accumulation of 
tliick, tenacious mucus, requiring considerable effort to dislodge it. The 
cough gradually becomes like that due to pulmonary disease, when the 
sputa assume a mucoi)urulent or i^urulent character. Kcemoptysls is not 
a common feature of tuberculosis of the larynx, and does not show itself 
until the ulcerative stage has been reached. The quantitj^ is always small 
unless the lung be coincidently involved. Occasionally it is possible to 
detect the exact site from which the blood comes. 

Local pain, with tenderness on pressure, may be present, both espe- 
cially severe if the cartilages have become involved. They are slight, 
even in cases of extensive lesions, provided the cough is not severe and 
the patient is not attempting to swallow, conditions which very seldom 
exist. The j9rt /;?/?(? swallowing met with in the last stages of the disease 
is notoriously common, and forms a most unhaj^py feature of the case 
to both physician and patient. The former is powerless to arrest it, 
except temj^orarily and to a slight extent, while the act of swallowing 
causes the patient so much pain that he i^refers to starve rather than 
take nourishment. Even when deglutition is not actually painful it 
is difficult, as, owing to the infiltration of the ei)iglottis and adjacent 
parts, their functional accuracy- is interfered with. Breathing is not, 
as a rule, early interfered with from purely laryngeal lesions. In the 
later stages there may be more or less dyspnoea if tlie free motion of the 
cords becomes impaired, especially by a lesion which may keep them 
parti}' approximated, or when there is some growth obstructing the free 
passage of air through the larynx. The encroachment on the lumen of 
the passage may be so great as to necessitate tracheotomy. 

The general symptoms are the same as those of active tuberculosis in 
any part of the body, — fever, sweats, emaciation, anorexia, rapid pulse, 
etc. In a suspicious laryngeal case it cannot be too strongly insisted 
upon that during the early stages, when the diagnosis may be uncertain, 
the chest must be repeatedly examined and comparisons made of the 
results. Perhaps at first the physical signs may hardly be of signifi- 
cance, but as repeated examinations are made and the symptoms become 
more developed, one can arrive at an accurate idea of the nature of 
the laryngeal lesion even though the latter may have been stationary. 
The sputa should be examined repeatedly according to methods now in 
vogue. 

These patients are frequently hopeful and energetic, and the very mild 
local symptoms in many cases are apt to mislead even the physician, who 
may attribute them to some catarrhal process in the passages higher up or 
to some other constitutional dyscrasia, not suspecting tuberculosis. 

Differential Diagnosis. — Given such a group of symptoms as above de 
scribed, a case of laryngeal disease suggests three special maladies, — 
malignant disease, syphilis, and tuberculosis. In syphilis there is apt 
to be a husky and hoarse rather than an aphonic voice, and pain is an 



632 DISEASES OF THE LARYNX. 

infrequent feature. Inquiry must be made as to the history of initial in- 
fection and the usual development of the different stages. Finally, there 
is the therapeutic test of potassium iodide, during which the patient 
must be closely watched, because sudden and even dangerous oedema is 
known to have followed its use. 

Malignant disease presents its own dyscrasia and pain is a pretty con- 
stant feature. Examination of the lungs is negative, and no bacilli are 
found in the sputa. If there be a general infiltration there may be an 
immobility of one side of the larynx, and if the growth be of such a shape 
that removal of a piece is possible, examination by the microscope may 
at once settle the diagnosis. Later stages will be attended by ulceration 
and a foul discharge, but it is in early diagnosis that the dif&culty lies, 
and the latter cannot always be made until the case has been watched 
for a time and the local changes closely noted. In tubercle, especially 
when supervening on disease of the lungs, the diagnosis may often be 
made from the history of the case, but the mirror enables the surgeon to 

determine the site, extent, and degree of the 
^^^•258. local change. A pallor of the mucosa is 

always suspicious. At first there may be only 
the usual changes of catarrhal laryngitis, but 
the local changes are not evenly distributed 
as in that affection, and are more apt to be 
confined to the aryepiglottic folds and ven- 
tricular bands. Sometimes there is a warty 
appearance in the interarytenoid commissure, 
Thickening of the epiglottis and and it may be possible to recognize tubercles 
arytenoid cartilages ; disease at left through the epithelial layer of the mucosa. 
SI" aroxB:r:r' '''''" ^^ «ie second stage there is noted a tu- 

mefaction of the covering of the arytenoid 
cartilages and of the aryepiglottic folds, giving the ''club-shaped" ary- 
tenoids. It is rare to find only one side thus affected, though both may 
not be equally involved. The finding of this condition is of the greatest 
significance, for while there may be at this point localized oedema under 
various circumstances, the x)ersistence of the lesion in association with 
other and constitutional symptoms renders the diagnosis positive. It is 
in the early stages of these cases of unilateral infiltration that diagnosis 
is difficult. An aid to diagnosis is the condition of the epiglottis, in 
which the infiltration is deposited along its crescentic edge, giving it a 
turban-shape. 

Ulcerations may now appear, starting as minute points, but gradually 
coalescing and finally covering extensive areas. The tubercular ulcer 
does not markedly differ in color from surrounding areas of infiltration ; 
its surface is slightly uneven. Unless the process has invaded the epiglot- 
tis and true cords, the loss of substance does not appear very noticeable, 
but if such invasion takes place the tissues seem gradually to disappear 




TUBERCULOSIS OF THE LARYNX. 633 

by a slow melting away. Finally, if any of the cartilages become necrosed 
and exfoliated, there occur varying conditions of distortion of the parts 
occasioned by their loss. 

Prognosis. — This is, of course, always unfavorable, but cases of re- 
covery from the local lesion have been reported. This is one of the more 
hopeful features of the progress in therapy during the last few years, for 
physicians have learned that much may be effected by energetic inter- 
vention, and they no longer content themselves with merely palliative 
routine measures. Cohen estimates his own recoveries as one per cent, 
of the total number of cases seen by him. Eecovery in this sense refers 
to the ability to resume occupation and to live for a varying num- 
ber of years, or, as stated by Delavan, ^ ' to call that case cured in which 
all trace of active disease has disappeared from the larynx and all ac- 
tive symptoms referable to that organ have passed away, particularly 
in which there is no recurrence of the local lesion during the remainder 
of the patient's life." Bobert Levy ^ would go a step farther and 
^^call a case cured in which all active indications of disease fail to recur 
after two or, in some instances, one year from their cessation." Levy's 
figures from his own experience are of interest. He conditions the 
prognosis on the nature and position of the lesion, combinations of 
lesions, i^ulmonary condition, coexistence of syphilis, and treatment. Out 
of one hundred and forty-four cases, of which eighty-four were of the 
infiltrative and papillomatous variety, twenty-six were at time of writing 
either worse or dead, but only eight of the twenty-six were influenced 
materiallj^ by the laryngeal complication. The remaining fifty-eight 
either got better or completely recovered. Out of sixty cases of the 
ulcerative varietj", thirty-seven grew worse or died, twenty-nine being 
hurried to an unfavorable ending by the laryngeal state. As regards the 
position of the lesion, he makes a general division into two classes, — those 
with intact ei)iglottis and aryepiglottidean folds, and those in which one 
or both of these structures have been invaded ; of one hundred and three 
of the former, all grew worse or died, and of forty- one of the latter, 
twenty-nine died. The presence of oedema, acute tuberculosis, or tuber- 
culosis of the pharynx decreases the chances of recovery. Pulmonary 
lesions, of course, do the same, though, as above stated, it is i)ossible for 
the larynx to heal while the lesion of the lung tissue steadily progresses. 
As to the coexistence of syphilis, he agrees with Schech that the progno- 
sis becomes the more unfavorable as the tuberculosis gets the upper hand. 

The importance of an early diagnosis with reference to the detection 
of tubercular disease cannot be too strongly insisted on, and the survey 
of the field in each case must be a broad one. Lennox Browne ^ urges 
that "it is as important to examine those portions which lie above the 

^ Jour. Am. Med. Assoc, September 16, 1899, p. 707. 
2 Jour. Laryngol, May, 1900, p. 274. 



634 DISEASES OF THE LARYNX. 

larynx suspected of being tlie subject of tuberculosis or pretubercular 
disease as to examine the lungs. For^ as has often been pointed out by 
others than myself, the little cloud predicting a storm can be often seen 
by the eye before the ear will hear the thunder." Such an examination 
will occasionally reveal some cause of irritation (such as an enlarged 
uvula) in a case presenting all the subjective and some of the objective 
evidences of incipient tuberculosis. Eemoval of the cause leads to a 
subsidence of all symptoms. The use of tuberculin in these early cases 
as a means of diagnosis has never been relied on to any great extent, at 
least in America. There can be no doubt, however, that it is an agent 
of considerable value. In the disappointment at its failure as a thera- 
peutic agent, physicians have lost sight of its real value as a means of 
diagnosis. Caution as to initial dosage must here especially be insisted 
on, as tuberculin injections have in some cases led to a temporary aggra- 
vation of the local condition, and, according to Browne, in two instances 
to an ulceration where previously the condition had been one of infiltra- 
tion only. 

It must not be forgotten that with laryngeal as with pulmonary tuber- 
culosis the later stages present the problem of mixed infection, for the 
destructive processes and accompanying inflammations are largely due to 
pus cocci, and the hectic features to the absorption of the toxins of these 
organisms far more than to those of the tubercle bacillus. 

Treatment. — This may be considered under the headings of hygiene, 
diet, climate, internal medication, topical applications, and surgical meas- 
ures. 

Hygienic treatment is naturally the same as that prescribed for general 
tuberculosis. Care must be taken that the skin is kept in healthy condi- 
tion by daily bathing. IsTo general rule can be laid down as to the tem- 
perature of the bath, as each case must be dealt with by itself. The aim 
should be so to arrange the details of the bath that the patient shall 
react well. The underclothing should be of wool suited in weight to the 
season and should be worn in the common combination suit. As much 
time as possible should be spent in the open air, and gentle exercise 
should be a part of the daily treatment. If there are sputa, the same 
care should be followed in their disposal as with the pulmonary cases, 
even though examination should not disclose bacilli. They should not be 
swallowed, but deposited in some cheap receptacle which can be burned 
together with its contents. The patient should live in well- ventilated 
rooms, the sleeping- room not being occupied in the daytime, if such an 
arrangement can be made. As much rest as possible should be given to 
the larynx and to the entire body. 

The food should be bland and unirritating, and in the earlier stages no 
special restrictions need be enforced except the avoidance of pastry, 
sweets, and other articles liable to derange the stomach. In the later 
stages the preparation of the food becomes a most important problem, 



TrBERCULOSIS OF THE LARYNX. 635 

owing to the great pain in swallowing. It should be concentrated, bland, 
and nnirritating, and in many cases it becomes necessarj^ to emploj^ some 
form of local anaesthesia before the taking of food. For this puri^ose 
sprays of cocaine or encaine have largely superseded the use of mor- 
phine, antipyrin, and similar substances. 3Iore recently', however, a 
newer remedy (orthoform) has been shown to be of the greatest value in 
the relief of the odyni)hagia of laryngeal tubercle. Orthoform is a whitish - 
yellow powder without odor or taste, and soluble in alcohol and hot 
water. It is a product of organic chemistry, being technically known as 
the methyl ester of para-amido-meta-oxybenzoic acid. Its slow solubility 
is one of its special advantages, and it is in a general way anaesthetic and 
analgesic, and is believed to act on exposed nerve-endings. It can be 
freeh' insufflated in powder directly upon the larj^ngeal ulcers or can be 
applied by carrier in some form of mixture. Combinations with men- 
thol have been found of service, and Freudenthal ^ recommends the fol- 
lowing emulsion: menthol, 10; ol. amyg., 30; vitelli ovi (two yolks), 
30 ; orthoformi, 12 ; aqmedest., 100. This may be ai^plied either with a 
cotton carrier or, as Freudenthal suggests, syringed directly into the 
larynx. AYhile some cases of dermatitis have been reported after the use 
of the remedy in external wounds of large area, no untoward results 
have followed its application in the larynx. It is a valuable addition to 
the physician's resources in this distressing condition of odynphagia. 

Another device, first published by Wolfenden, who received the sug- 
gestion from a patient, is that of having the patient lie flat on his 
stomach, with his head over the edge of a couch, and draw up through a 
tube liquid nourishment from a vessel at a lower level, — i.e., drink as a 
horse drinks. It is found that many patients can in this way swallow 
with comparative comfort, when in the erect posture the act is agonizing. 
Still another plan that may be of service is the use of the soft-rubber 
catheter passed into the oesophagus, and through which, either by means 
of a rubber bag or funnel, nourishment is poured, or to which is attached 
the tube from a forcing-bottle, so that the food is in a way pumped into 
the oesophagus. All the foregoing must be looked upon, however, only 
as temporizing measures, serving to make the last days of the patient 
comfortable. 

Climatic treatment does not seem to have any si^ecial effect upon 
laryngeal tubercle apart from that on tuberculosis generally. What will 
benefit the latter will, of course, benefit the former, and the improvement 
in the two conditions will go on pari j^assu. Eemoval to a proper climate 
does not annul the possibility of the development of laryngeal disease. 
Bad cases of the local disease ought not, even if the general condition be 
fairl}^ good, to be turned loose in any climate, however ideal, but should 
be treated in sanitaria in favorable x>laces. Much can be done with 

» Philadelphia Med. Jour., March 25, 1899, p. 688. 



636 DISEASES OF THE LARYNX. 

fresh-air measures, even when the patient cannot leave home. If the 
house has a veranda, it can be sheltered by movable partitions or sides, 
so that the patient can remain much of the time in the open air, but 
must be well wrax^ped uj) and the feet kept warm. No remedy has yet 
been found which seems to have any special effect upon laryngeal tuber- 
culosis aiDart from its effect upon the general condition. This is only 
what might be expected, for physicians must look upon the laryngeal 
condition as merely one of the many expressions of the general diathesis, 
modified only by local anatomical and physiological conditions. No 
remedy specific against tuberculosis has yet been found. Hyi)odermic 
injections with various tuberculins, serums, and other compounds are 
vaunted from time to time, but soon fall into oblivion : the excellent 
results ascribed to most, if not to all, of them cannot be verified. It is 
fortunate indeed that the profession has passed from the era in which 
the only remedies were quinine, iron, and cod-liver oil to a period of 
more active therapy. Yet the results obtained in these later years have 
come about more, x>erhai3S, from the treatment of the iDatient than the 
treatment of the disease, — that is, so far as the general diathesis is con 
cerned. All have learned the valuable lesson that digestive power and 
bodily energy are to be kept at their best, and that anything militating 
against these cannot be a rational therapy against the ravages of the 
tubercle bacillus. 

Passing to the consideration of definite internal remedies, it may be 
noted that Shurly ^ states that he has found the iodine compounds more 
serviceable than any others, and he adds the valuable suggestion that the 
associated or combined administration with some proteid material is of 
great utility. He advises the use of guaiacol, creosote, or iodine prepara- 
tions in either bouillon or milk. 

There is no doubt in the writer's mind that valuable results are ob- 
tained by the use of creosote, though opinions may differ as to whether 
it has any specific effect or acts merely as an efficient intestinal anti- 
septic under the conditions considered. It can be given in pill form 
or in that of one of the various preparations which have been devised 
by manufacturing chemists, such as creosote with liquid pei^tonoids. 
Little is to be gained, and perhaps much is lost, by endeavoring to satu- 
rate the system with the remedy, or by seeing how large doses the stomach 
can tolerate. Much more benefit, it would seem, is derived from cod- 
liver oil nowadays than formerly, for improved methods of preparation 
have produced emulsions in which the oil is much more finely subdivided 
than before, and the absorx^tion of it is therefore more comx^lete. Other 
familiar remedies are the various hypophosphites and similar x^repara- 
tions. It is well to vary the combination given from time to time, so as 
to prevent gastric disturbance. 

^ Amer. Text-Book of the Eye, Ear, Nose, and Throat, p. 1048. 



TUBERCULOSIS OF THE LARYNX. 637 

For the cough there is, in addition to the old and time-honored com- 
bination of remedies, a new substance (heroin), a derivative of morphine. 
The dose is from one- twelfth to one-sixth of a grain every three or four 
hours. Too large dosage may occasion drowsiness and constipation with 
some giddiness and depression of the respiration. Ordinary dosage is 
free from these effects, and the remedy does not derange the stomach. 
In some instances cough is relieved by taking thirty or forty drops of a 
mixture of ecxual parts of the fluid extract of ergot and hydrastis in a 
little water four or five times daily after eating. If cocaine is to be used 
to relieve the irritability inducing cough, an excellent combination is 
made of sixteen grains of cocaine with eight grains of resorcin in one 
ounce of water. The resorcin prevents the cocaine from crystallizing 
and the solution from decomposing, while it seems to increase the anaes- 
thetic and diminish the toxic power of the cocaine. The addition of 
two per cent, of sodium sulphate to a five per cent, solution of cocaine 
decidedly increases the effectiveness of the latter, partly by reason of its 
penetrating power and partly owing to its action upon the globulins and 
other proteids which occur in the secretion (Wyatt Wingrave). 

The topical treatment needs to be carefully carried out in order to 
make the patient as comfortable as possible, even if it does not check 
tlie general deterioration in health. AVhen a i^atient first comes under 
observation, the throat is often so irritable that little can be done even 
in the way of examination, much less treatment. Under these circum- 
stances he should be i^laced on the treatment suggested under the head 
of acute laryngitis until the local irritability^ has subsided and the physi- 
cian is able accurately to locate the lesion and decide upon the plan of 
treatment. Local cleanliness must form an essential part of whatever 
plan is adoj)ted. Several times daily the larynx should be sprayed with 
a solution of hydrogen dioxide (which can be diluted with lime-water) 
or with a solution of enzymol, which is a i^roteolytic ferment of much 
value in clearing away dead tissue. It should be diluted with an equal 
part of warm water, and can be sprayed in freely. It has but a slight 
and in no waj' disagreeable taste, is non-irritating, and does not act on 
living tissue. The author believes it to be sui)erior to hydrogen dioxide 
for this x)urx)ose. This is to be followed by some warm dilute alkaline 
solution, as Dobell's, the Seller tablet, listerine, etc., to thoroughly' clean 
the affected i)art. Then, if there be merely an infiltration, some alterative 
solution, such as MandFs (iodine, five grains 5 potassium iodide, ten 
grains ; carbolic acid, two minims ; glycerin, one-half ounce), may be 
applied, and a powder composed of equal parts of bismuth subnitrate and 
iodol immediatelj' insufflated. The oleostearate of zinc, a white, creamy 
preparation, may be used as the vehicle for various alterative drugs. 

Menthol has long enjoyed a favorable reputation. It may be applied 
in a twenty per cent, solution in olive oil by either cotton carrier or spray. 
While the number of cures reported from its use is very small, there is a 



638 DISEASES OF THE LARYNX. 

consensus of opinion as to its value in relieving the severity of all the 
local symptoms. Iodoform also enjoys considerable favor. The surgeon 
may, however, obtain equally good results with some other combination 
of iodine, such as iodol. The list of remedies of this class includes also 
europhen, thiocol, and peronin. Another useful compound for applica- 
tion to an extensively ulcerated surface is made up as follows : mor- 
13hine muriate and cocaine muriate, of each, one-quarter grain ; boric acid 
and iodoform, of each, one grain ; the whole to be insufflated two or three 
times daily. It may be given before meals to relieve dysphagia, or at 
bedtime to induce sleep. As long, however, as the use of morphine can 
be avoided, the better for the digestion. Lactic acid, being generally 
used in connection with curetting, will be considered in the following 
paragraphs. 

Surgical Treatment. — Tracheotomy is occasionally necessary for the 
relief of dyspnoea due to oedema. It should be performed as low down 
as iDOSsible. It is merely a palliative measure, thought a few cases have 
shown remai'kable improvement in the intralar^'Ugeal condition after 
the organ has been placed at rest by the operation. Life is prolonged 
and the patient made more comfortable. Extirpation of the larynx, 
once proposed, is not to be thought of in this connection. Of the 
measures designed for the interior of the organ, there maj^ be mentioned 
first the method of incision of the cedematous tissues by means of knives 
or curved scissors, suggested by Moritz Schmidt and others some fifteen 
years ago, and later it was considered well to apply lactic acid to these 
incisions. Incision is followed by the escape of blood and serum, and the 
procedure seems to give considerable relief to local symptoms. 

Heryng has suggested the injection of lactic acid into the diseased 
tissue, but this is a painful method and has given way to those now to be 
mentioned. These are the scraping or curetting of the ulcer, suggested 
by Heryng, followed by the application of lactic acid well rubbed in and 
the cutting away of diseased tissue by means of sharp spoons, as sug- 
gested by Krause, who also uses lactic acid after the operation. 

The literature on this form of treatment has now become very 
voluminous, and there seems no reason to doubt that the foregoing 
method, modified, perhaps, in minor details to suit individual cases, offers 
the best means at one's disposal for the healing and possible cure of 
laryngeal tubercle. Heryng' s ^ views have been summarized by Gleits- 
mann '^ as follows. Curetting and the use of lactic acid are indicated : 
(1) In cases of primary tuberculosis without lung complication. (2) In 
cases of lung disease either incipient or at least short of softening 
and hectic. (3) In circumscribed ulcerations and infiltrations. (4) In 
the dense hard swelling of the arytenoid region, the ventricular band, 

1 Jour, of LaryngoL, 1893, p. 361, and 1894, pp. 193, 227, 471. 

2 Trans. Amer. LaryngoL Assoc, 1895, p. 136. 



TUBERCULOSIS OF THE LARYis^X. 



639 



the posterior T^'all, tubercular tumors, and affections of the epiglottis. 
(5) Even in advanced pulmonary disease it is a justifiable measure for 
the relief of the intense dysphasia. 

The curettes in most common use are the single instrument of Heryng 
for cleaning ulcerated surfaces and his rotary instrument for the excision 
of tubercular infiltrations. A double curette for the latter purpose has 
been devised by Krause. Local anaesthesia is secured by cocaine. If 
the operation be at all extensive, it is better to perform it in a hospital, 
where the patient should remain for a few days and rest where aid 
can be promptly summoned in case any emergency arises. Lactic acid 
should be rubbed in at the time of operation, commencing with a watery 
solution of ten or twenty -per cent, and gradually increasing it u^) to sixty 

Fig. 259. 




Heryng's laryngeal knives and curettes. 



or eighty. Botey has recommended an application of one part of lactic 
acid, two of carbolic acid, and twenty of glycerin, cocaine being i^re- 
viously applied. This preparation is somewhat emollient and more 
adherent than an aqueous solution. The strength of the acid is gradually 
increased as tolerance is established. 

Mention should also be made of the submucous injection of creosote 
by means of a long, curved needle attached to a suitable syringe. 
Chappell prefers for this pur2:>ose the following combination : beech- 
wood creosote and oil of wintergreen, of each, two drachms ; hydrocar- 
bon oil, one drachm ; castor oil, three drachms. He has devised a 
special syringe which discharges its contents quickly by means of a 
spring action. 

The use of the galvano-cauteiy is not to be advised, though it has had 
its advocates. In the hands of some clinicians, electrolysis has yielded 



640 DISEASES OF THE LARYNX. 

very fair results. W. Scheppegrell/ among others, has recommended 
cupric interstitial cataphoresis under direct laryngoscopy. He states 
the following as the advantages of this method. (1) There is no real 
destruction of tissue, so that no new areas are opened for possible re- 
infection, as with curettage, the galvano-cautery, and simple electrolysis. 
(2) There is no reaction or hemorrhage. (3) There is no high degree of 
manipulative skill required as in some of the other methods. (4) The 
plan is applicable to all cases. 

From what has been presented under the head of treatment, it will be 
seen that, while there is no specific for the affection, and only compara- 
tively few cases are permanently benefited, mucli can be done to make life 
comfortable, and each case should be carefully studied with a view to 
ascertaining which plan is likely to be the most beneficial. As several 
observers have remarked, the aim should be not so much to find out new 
remedies as more accurately to determine the proper indications for those 
already possessed, and particularly the safe limits of the more radical 
surgical procedures. 

1 New York Med. Record, May 29, 1897, p. 767. 



CHAPTEE XVL 

SYPHILIS AND LUPUS OF THE LARYXX. 
SYPHILIS OF THE LAEYXX. 

Under this headiug are placed congenital manifestations and the 
primaiy, secondary, and tertiary varieties of the acquii^ed form. 

The manifestations of hereditary specific taint in the earliest years of 
life have been studied by numerous writers^ among whom J. X. Mackenzie 
and Arslan may be specially mentioned. Arslan.^ whose views may be 
taken as representative of those of Continental clinicians, does not believe 
the condition as common as does Mackenzie, who records seventy-six 
cases, fifty-three of which occurred under one year of age. Some of the 
sudden attacks of oedema and other suffocative seizures of early child- 
hood may have as their foundation a sj'iihilitic taint the existence of 
which is not suspected, and, as no autopsy is made, the true nature of the 
malady is never known. Mackenzie - saj'S that '' laryngeal lesions have 
not been found more frequenth^ simply because they have not been 
sought. Laryngeal disease is not rare in congenital syphilis ; it is one 
of the most constant and characteristic of the pathological i)henomena, 
and we may look for an invasion of the larynx with as much confidence 
in the congenital as in the acquired form of the disease.'' The symptoms 
in such children may take the form of a general wasting and cachexia, 
together with such local manifestations as a husky voice, difticult swal- 
lowing, short cough, labored breathing, etc., with frequent attacks of 
laryngismus stridulus. Prognosis improves with the age of the child. 
The diagnosis is often difiioult, though one may be aided by examination 
of the body for the ordinary stigmata of the syphilitic diathesis. The 
therai)eutic test may alone confirm the diagnosis. 

Treatment calls for the prompt administration of mercurials. Medi- 
cation of the infimt through the uncertain channel of the breast- milk is 
no longer followed. One may use ten grains of the official unguentum 
hydrargyri rubbed uj) with an equal quantity of white vaseline under the 
same general precautions which govern inunction methods in general, or 
one may give four times daily to an infant of one year, gray x)owder, 
one grain, or mercuric bichloride, one-sixtieth grain, or, if haste is re- 
quired in bringing the system under the effect of the remedy, calomel, 
one- tenth grain. If any of the lesions can be discovered which in the 
adult are classed as tertiary (in which case there will probably be found 

1 Arch. Iiiternat. de Lar., 1897, vol. x. p. 383. 

2 ^^1^^^ joui,_ ^Iq^ gci., October, 1880, p. 321. 

41 641 



642 DISEASES OF THE LARYNX. 

bony and visceral evidences), one may add potassium iodide in daily 
dosage of twenty grains. The giving of the latter in milk to which a 
pepsin ferment is added, as recommended by Delavan, so as to form a 
junket, is an admirable method. The possibility of a tracheotomy or 
intubation must be provided for in exceptional cases. 

The diagnosis of the hereditary forms, as occurring in later years, is 
always difficult and, from objective appearances alone, often impossible. 
Botey^ notes the following characteristics of the condition. (1) Late 
hereditary syphilis always occurs under the tertiary form. (2) This form 
consists of ulcerating gummata, accompanied by vegetating hyperplasia 
of the tissues. (3) The course is always much slower than that of ac- 
quired tertiary disease, a fact which makes it resemble, and often causes 
it to be confounded with, laryngeal tuberculosis. (4) It is often accom- 
panied by syphilitic lesions of the pharynx and nasal fossse, which are 
excessively rare in tertiary acquired laryngeal disease. 

Ebstein ^ thinks that hereditary manifestations are more common on 
the epiglottis than at other laryngeal sites. 

The various characteristics of the syphilitic lesions at varying periods 
of the evolution of the affection have been considered when speaking of 
syphilis of the pharynx. The x^i'imary lesion is naturally almost unheard 
of ; Moure ^ has reported one case in a young man of twenty- three years, 
the chancre being on the left free border of the epiglottis. The writer 
can find no other case of this kind on record, and it must be placed in 
the category of clinical curiosities. 

The secondary lesions are, as a rule, later in their manifestations in 
the larynx than in other parts of the body. The earliest and most 
common lesion is the erythema, which may come on as early as six weeks 
after infection. As a rule, however, its appearance is delayed for from 
four to six months. In its early stages it resembles ordinary catarrhal 
laryngitis both in appearance and symi^tomatology, and, in the absence 
of definite specific evidences elsewhere, diagnosis may for a time be 
difficult. Sometimes the color is more deeply red and the swelling 
greater, while the mucosa has a semi-cedematous look. The erythema is 
due to an infiltration of the mucosa with small round cells of a low 
grade of development, whereby venous return is interfered with, thus 
leading to venous congestion, diifused or in patches. It is regularly seen 
at the entrance to the larynx, involving the posterior surface of the 
epiglottis, arj^epiglottic folds, and false cords, but rarely the true cords. 
The diagnosis of these cases must often depend on the history of the case 
and the results of treatment. If the infiltration of the mucosa be deep, 
there is a patchy appearance of irregular thickness and not likely to be 

1 Ann. des Mai. de 1' Oreille, May, 1894, p. 454. 

2 Wien. Klin. Woch., 1898, No. 48, S. 1110. 

3 Leeons sur les Mai. du Lar., Paris, 1890, p. 229. 



PLATE XI. 

Syphilis of the larynx, especially of the vocal bands. (J. Schnitzler. ) 

Figs. 1 to 4 show the early forms of syphilis of the larynx. The conditions rep- 
resented in these four figures date from the fourth, the sixth, and the eighth week 
after infection. 

Fig. 1, redness and swelling of the vocal bands ; the left vocal band shows on its 
edge a dark red spot which is shai-ply defined by a grayish- white line. 

Figs. 2, 3, and 4 show the varied forms of syphilitic papules on the vocal bands. 
These small, gray-white, mostly round or oval infiltrations are characteristic of 
syphilis. 

Figs. 5 and 6, appearances of the larynx several months after infection. Irregular 
ulcers on the vocal bands characteristic of syphilis of the larynx. 

Fig. 7, comparatively circumscribed, but deep, syphilitic ulceration on the right 
vocal band in process of healing. 

Fig. 8, complete destruction of the left vocal band, the vocal process alone intact. 
On the left ventricular band distinct cicatrization. 



PLATE XL 



T^r^_ 



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SYPHILIS AND LUPUS OF THE LARYNX. 643 

mistaken for anything else. The mucous patch may be found on the 
vocal cords and, according to some writers, on the areas mentioned as the 
possible seats of erythema. It is one of the rare laryngeal lesions of 
specific disease. Erosions of various depths occur, the superficial being, as 
with the process in the pharynx, the result of the breaking down of either 
the mucous patch (page 505) or a sui^erficial gummatous infiltration. 
The mucous patch suggests a search for skin lesions, generally of the 
j)apulo- squamous variety. Sometimes they take the form of condylo- 
mata, which are probably nothing but aggravated mucous patches. Oc- 
casionally in the secondary stage distinct tubercles form, breaking down 
later into cup-shaped ulcers with thickened edges. The details of these 
processes have been spoken of under the heading of syphilis of the 
pharynx. The shape of these superficial ulcers is rounded or oval, and 
they secrete pus of normal appearance. Under manipulation they easily 
bleed, but do not have the angry zone of an inflammatory process. 

The most imj)ortant lesion of laryngeal syphilis, in the sense of 
frecxuent occurrence and of potentiality for harm, is the gummy tumor, 
which, as a rule, does not appear until some six or eight years after the 
initial lesion, during which time the larynx may have given no symptoms 
whatever. The gummatous deposit may be diffused or circumscribed. 
In contrast to the lesions above noted, it affects the deeper layers of the 
mucosa and the cartilaginous structures. More generally when the cases 
come under observation the infiltration has become ulcerated ; this early 
breaking down is due to the facts that the larynx is never at complete 
rest and that the irritation thereby caused to the mass leads to its early 
destruction. Occasionally tumor-like masses are seen, and it may be 
necessary to make a diagnosis between them and malignant disease. The 
obvious indication is always to give potassium iodide tentatively in cases 
of intralaryngeal growth, but to bear in mind the fact that potassium 
iodide will sometimes cause the subsidence of the inflammatory infiltration 
which forms a zone around a true malignant process. A hoi^eful -prog- 
nosis cannot, therefore, be given from the immediate happy effects of the 
remedy. Inunctions of mercury may also be necessary. Bosworth quotes 
an Italian observer named Luca who saw a gummy tumor which had been 
attached to the x)Osterior wall of the larynx for twenty-six months with- 
out change, yet it finally disappeared under antisyphilitic treatment. 
The symx)toms of a gummy tumor will depend on its site and size, and 
consist of discomfort, though not much actual pain, some difficulty in 
swallowing, especially when the invasion is at the i)Osterior part of the 
larynx and afi'ects the oesophagus, and possibly dyspnoea. The sudden 
apj)earance of these masses and their stationary size, unless they decrease 
by ulceration, are points of value in diagnosis. The result of an untreated 
gumma, and sometimes in spite of treatment, is the formation of a deep 
tertiary ulcer. This develops from one or more sites over the infiltrated 
areas and burrows deeply down to the cartilages. The epiglottis is most 



644 DISEASES OF THE LARYKX. 

frequently attacked, and may be partially eroded or even completely 
destroyed. The true cords are next attacked, then the false cords and the 
posterior commissure. If the process extends to the cartilages, a peri- 
chondritis and chondritis are set up, with their own symptoms added. 

Diagnosis must be made between this and tuberculosis, luj^us, and 
malignant disease. The diagnostic points of value have been partly 
suggested in previous chapters. The syphilitic ulcer is excavated, 
covered with a grayish secretion, surrounded by an angry red zone, has 
sharp, well-defined edges, and, if it has progressed to any great extent, 
will appear in the midst of more or less necrotic tissue. I^otwithstand- 
ing these definite characteristics, the diagnosis between tubercular and 
specific ulcers is, in the absence of collateral evidence, impossible from 
mere inspection, and one must call to one's aid the results of examina- 
tion of matters expectorated and the effect of giving the iodides. The 
question is still further complicated by the possibility of a coexistence 
of tubercle and syphilis. These cases of dual infection are rare. Accord- 
ing to Fasano, syphilitic disease in the larynx may change into tubercu- 
lar. He explains this change on the assumption that, both maladies 
being of a bacterial nature, the micro-organisms of one disease may pre- 
vail over those of the other and gradually destroy them. How and when 
this change takes place is a matter of doubt, as the evidence is only 
clinical. Therefore, Fasano believes that the question is not one of sym- 
biosis, — that is, the coexistence of the two maladies, — but of transforma- 
tion of one to the other through the action of the tubercle bacillus 
through the lymphatics. It is generally agreed that in cases of dual in- 
fection the treatment of the specific element should be begun first. 
Damieno ^ believes that it is impossible, in the absence of the bacillus 
of Koch, to distinguish between the two. The exact local conditions 
greatly change with the death of the tissue and vary according to the 
methods of demonstration. In the syphilitic tissue he finds a more ready 
tendency to ulceration and fewer giant cells. Both lesions are to be 
regarded as granulomata. " As bacteriology gives us examples of micro- 
organisms which exist well together, so it also shows instances of antago- 
nism which reaches such a point that one germ destroys the other. A 
similar condition should occur when a tubercular lesion is superposed 
upon a syphilitic one." 

E. Lang ^ says that syphilis may by its manifold histological changes, 
perhaps also by the action of the toxin derived from the specific con- 
tagium, cause such essential alterations that the entire body is thereby 
weakened and more readily attacked by other partly functional, partly 
organic affections. Long-standing syphilitic skin lesions finally assume 
a lupoid appearance, and in such cases the actual presence of tubercle 



^ Cf. Jour. Laryngol., 1894, vol. viii. p. 384. 
^ Twentieth Century Med., vol. xviii. p. 280. 



PLATE XII. 

» 

Gummata and profound destruction of tissue in consequence of breaking down 
of infiltration. Late stages of syphilis, mostly several years after infection. (J. 
Schnitzler. ) 

Fig. 1, characteristic irregular ulcers on the edges of both vocal cords ; in addi- 
tion a round, almost typical, ulcer on the left arytenoid cartilage. 

Fig. 2, irregular ulcer on the laryngeal surface of the epiglottis, left side, with 
beginning ulceration on the left vocal band and left arytenoid cartilage. 

Fig. 3, ulcer on the left ventricular band, with lardaceous, purulent covering. 

Fig. 4, intense swelling of the epiglottis ; the latter is unrecognizable by reason 
of diffuse infiltration. Entrance to the cavity of the larynx entirely occluded. On 
the left half of the epiglottis a deep, irregular ulcer with lardaceous covering ; a 
second crater-like ulcer on the outer surface of the right arytenoid cartilage extending 
to the aryepiglottic fold. 

Fig. 5, advanced syphilis of the larynx. Characteristic ulcers following breaking 
down of gummous infiltration on the edges of the epiglottis and on the outer surface 
of the arytenoid cartilage. Dirty gray, deep ulcers with lardaceous covering and 
circumscribed by sharply defined edges. 

Fig. 6, the same larynx after several weeks of antisyphilitic treatment. Cure of 
ulcers, with great loss of tissue. Characteristic cicatrices. 

Fig. 7, extensive and deep destruction of the larynx, especially of the epiglottis 
and arytenoid cartilage. 

Fig. 8, same case, healed by systematic antisyphilitic treatment. 



PLATE Xir. 








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SYPHILIS AND LUPUS OF THE LARYNX. 645 

baxiilli lias been demoustrated by Sasakawa. If this liai^peus in the skin, 
it is a justifiable assumption that like changes may occasionally take 
place in neighboring organs. The deep ulcer is not in itself immediately 
dangerous ; it may exist for years Tvithout special annoyance, though 
Ludwig Tiirck ^ has reported one case of tatal hemorrhage under these 
circumstances, the ulcer being situated on the vocal cord. Occasionally 
glottic sx)asm or sudden oedema may supervene and the ]3atient succumb 
unless the facilities for an immediate tracheotomy are at hand. The final 
stage is that of cicatricial contraction varying in extent and location, and 
causing interference with phonation and respiration. Small ulcers, even 
if deep, may leave no trace behind tliem, though, if they be on the true 
cords, very small cicatrices may interfere with perfect intonation. The 
loss of the epiglottis does not especially interfere with deglutition, for the 
patients learn to so contract the muscles of the larynx as to cause its 
closure during swallowing. Adhesions of the epiglottis to the surround- 
ing structures are very frequently observed, the epiglottic ligaments and 
the arytenoid cartilages being the sites of attachment. Eischawy ^ re- 
ports a case of complete adhesion of the epiglottis to the root of the 
tongue without any loss of substance, but here there was no interference 
with swallowing. In the interior of the larynx are frequently found 
cicatricial bands reaching from one point to another. A most unfortunate 
phase of this process is that in which ulcerations occur on symmetrical 
areas of the vocal cords, for then adhesions and a narrowing of the air 
aj)erture are likely to take place. The adhesion is generally at the 
anterior commissure and progresses backward, finally leaving (between 
the cords) a posterior irregular opening with curved edges. One cannot 
estimate the probable severity of symptoms from the size of the opening 
left 5 small openings may present no dyspnoea, while it may be present in 
large ones. In such cases there is special danger of oedema of the glottis 
or of glottic spasm. Patients liable to attacks of dyspnoea, however 
slight, ought to be in a hospital, for the attacks may come on at any 
time, requiring immediate surgical intervention. Another dangerous 
condition is found in ulcerations simultaneously occurring on the rim 
of the epiglottis and the surrounding pharyngeal walls, for the entrance 
of the larynx may become blocked, causing serious dysphagia and dysp- 
noea. All forms of laryngeal distortion may be seen, and even when the 
larynx itself is free, similar lesions may be present in the subglottic region 
or in the trachea, manifesting the same symptoms and calling for the same 
treatment. At times it may be difficult, from mere objective appearances, 
to distinguish between cicatricial contraction due to specific disease and 
that due to lupus. The latter disease, however, does not present ulcera- 
tions as does syphilis, and the amount of cicatricial tissue is much less. 

1 Klin, der Krankh. d. Kehlkopfs, AVien, 1866, S. 413. 

2 AVien. Klin. Rundsch., 1899, Xo. 28, S. 453. 



646 DISEASES OF THE LARYNX. 

Treatment. — The treatment of laryngeal syphilis is similar to that indi- 
cated for the malady in general. Erythema usually disax)pears promptly 
under the mixed treatment, and local irritation can be allayed hj the 
measures employed in simple acute laryngeal catarrh. The same may be 
said of the mucous patch. Ulcerations, if superficial, should be si^raj^ed 
with a weak cleansing solution, and then a powder, such as iodoform, 
iodol, etc., insufflated. It may be said that, in spite of the many substi- 
tutes which have been proposed for iodoform, it easily maintains its su- 
premacy for the purpose indicated. The deep ulcer and gumma require 
the systematic use of the iodides in increasing doses, which may after a 
while be gradually decreased and then increased again. In this way the 
same results seem to be secured with a minimum likelihood of any annoy- 
ing disturbance of bodily function. For the relief of cicatricial stenosis 
many forms of dilating and cutting instruments have been devised ; the 
large intubation-tube here finds a valuable field of application. The 
possibility of oedema from the iodides must not be forgotten. All these 
cases must be watched, for no matter how brilliant the immediate results 
of treatment may appear, there is always danger of relapse. 



LUPUS OF THE LARYNX. 

The common opinion concerning the relations of lupus and tubercu- 
losis has been mentioned when speaking of lupus of the pharynx. Lupus 
of the larynx is comparatively a rare disease. As a rule, it is a later 
localization of the skin lesions of the same disease, but cases are recorded 
in which the laryngeal has preceded the cutaneous affection. A fair 
estimate would be that from eight to ten per cent, of all cases of skin 
lupus show, sooner or later, evidences of laryngeal invasion, which may 
occur without any manifestation in the intervening faucial regions. 

Etiology and Fatliology. — Lupus in general appears to be one of the 
manifestations of the scrofulous diathesis. Its general characteristics have 
been mentioned in the chapter alluded to, and need not be repeated here. 
Of the laryngeal cartilages the epiglottis is the one most often attacked, 
though the arytenoid may share in the process, in which is found the 
same formation of nodules, ulcerations, and contraction. The ventricular 
bands and aryepiglottic folds are perhaps the favorite seats of the process 
in the soft parts. 

Symptoms, — From the very slow development of the disease the symx)- 
toms in the larynx may for a long time hardly be noticed. These cases 
more often come under the dermatologist's care. Finally, a husky voice 
leads to a laryngeal examination, and the site of involvement of the 
larynx is discovered. The vocal impairment presents no peculiar features, 
but simply varies in degree according to the affection of the true cords 
or the ventricular bands and posterior commissure. Pain in swallowing, 
if present at all, is but slight. If the deposits in the larynx be so situ- 



SYPHILIS AXD LUPUS OF THE LARYXX. 647 

ated as to eucroach immediately upon the breatliiug space, dyspnoea is 
experienced, whicli is perhaps the most serious feature of the disease. 
The inflammation and oedema which accompany so many other intra- 
laryngeal i)rocesses are here wanting. As a rule, wasting of tissue takes 
place rather than swelling and consequent dyspnoea. 

Frognosis and Diagnosis. — Except in those cases attended by laryn- 
geal stenosis, the disease is not especially fatal, though it may continue 
indefinitely. Fortunatelj^, it would seem that if the stenosis occurs at all, 
it comes on early in the course of the malady. The diagnosis has to be 
made between this malady and tuberculosis, sj-philis, and, at times, malig- 
nant tumors. In tuberculosis the disease is more apt to attack patients 
about middle life, while lupus is found in the earlier decades. There is 
no constitutional disturbance in lupus, no lung lesion ; pain is wanting or, 
if j)resent, onlj^ slight, and usually there are found skin lesions which at 
once suggest the nature of the disease. The interior of the nose should 
always be looked at in these cases, and the long continuance of the case 
will also be of assistance in forming an opinion. Syphilis presents its 
own history, is, as a rule, without pain, and at the i:>eriod when it may 
have to be distinguished from lupus exhibits no constitutional symptoms. 
The therapeutic test will also help in diagnosis, as mercury and the 
iodides seem to render lujius distinctly worse. It is perhaps in the 
I)harynx and palate that the distinction between these two affections 
is the more difiicnlt. In malignant tumors the age of the patient, marked 
pain, rapid course, cachexia, etc., will generally suffice to make a 
diagnosis. 

Treatment. — The same general tonic course should be followed as for 
the lesion in the x^harynx ; so also with the local measures. The effect of 
the X-rays as a therai:)eutic agent here suggests possibilities which may 
prove to be of some definite value in radical cure. In the cases attended 
by stenosis the question of tracheotomy comes uj). Fortunately, the 
slow course of the disease gives ample time to fully consider the appli- 
cability of the procedure to each case. 



CHAPTEE XYII, 

TUMORS OF THE LARYNX. 
BENIGN^ TUMORS OF THE LARYNX. 

The laryngologists of to-day see fewer laryngeal growths than did 
their predecessors. Moreover, American practitioners do not appear to 
observe as many cases as do their English colleagues, nor the latter as 
many as the Continental clinicians. J. Wright has suggested that pos- 
sibly the prompt attention given in America to affections of the nasal 
cavities may have some relation to the comparatively small number of 
laryngeal growths. The older civilization in the European countries may 
also be a factor in the result. 

Etiology, — In the great majority of cases no definite cause can be as- 
signed for such growths. Some seem referable to vocal strain, others 
follow eruptive fevers, exposure to cold, and irritant inhalations, but a 
previous catarrhal condition is not found with any regularity, and a few 
cases of congenital tumor-growth are on record. 

Symptoms. — These consist of interference with phonation and, in the 
more marked cases, of disturbance in respiration. If the growth be situ- 
ated at some site other than the vocal cords, such as the aryepiglottic 
folds, epiglottis, or ventricular bands, and so lies that the approximation 
of the cords is not interfered with, it may reach a surj)risingly large size 
before attention is drawn to the condition. A j)edicled growth may, 
from its varying position, sometimes give rise to symptoms and again to 
none. Supraglottic neoplasms often cause cough, but pain is rare. Spon- 
taneous bleeding is rare, though blood may escape as the result of at- 
trition, but free bleeding suggests malignancy. Eespiration may be so 
gradually interfered with that no special difficulty is experienced until 
a severe cold develops an additional impediment from swelling of the 
mucosa. Glottic spasm is not unusual, while dyspnoea is more common in 
connection with infraglottic masses. 

Prognosis . — Unless the tumor attains such a size as to obstruct the 
breathing passage, or, being pedicled, falls into the glottis and sets up 
a spasm, the prognosis, so far as danger to life is concerned, is in a gen- 
eral way good. Except with papilloma, the growths do not, as a rule, 
recur after complete removal. Prognosis as to entire restoration of the 
voice after removal is generally good. 

Treatment. — In cases of urgent dyspnoea, intubation or tracheotomy 

may be necessary. As a rule, the treatment resolves itself into removal 

by cutting instruments or by destruction of the mass in situ. The former 

requires various forceps, of which there are many varieties, snares, and 

648 



TUMOJRS OF THE LARYNX. 



649 



guillotines. lu many cases the snap -guillotine serves admirably. For- 
cerps are sometimes used to crusli the growth, with a view to its sub- 
sequent disappearance by absorx)tion. Small sessile growths may be 
destroyed by either chromic acid or the galvano- cautery. Lennox Browne 
regards the use of chromic acid as attended by risk out of all proportion 
to any i)ossible chance of benefit, while as to the galvano-cautery he re- 
iterates his statement of twenty years ago, that it is a dangerous instru- 
ment to use below the level of the epiglottis. It is evident that the shape, 
size, and location of the growth will determine the choice of the means 
of removal. Ordinarily, in adults at least, these operations are per- 
formed under local anaesthesia. In children general anaesthesia is neces- 

FiG. 260. 





Mackenzie's laryngeal forceps. 



sary, and Scanes Spicer strongly recommends chloroform, with the local 
employment of cocaine to control excess of secretion. 

Semon's well-known collective investigations have shown that the 
probability of the transformation of benign into malignant growths is 
extremely remote. In some instances there has been a spontaneous expul- 
sion of the tumor. 

The fqllowing varieties of benign growths, given in order of relative 
frequency, are found in the larynx : papilloma, fibroma, cystoma, myx- 
oma, lipoma, angioma, adenoma, enchondroma, lymphoma, and colloid 
growths. Papillomata are more common than all other forms combined. 
They occur by i)reference on the anterior third of the true cords, less 
often on the aryepiglottic folds, ventricular bands, and epiglottis, the 
right side being oftener affected than the left. The tumors may be single 
or multix)le, sessile or pedicled, smooth or with a cauliflower-like surface. 



650 DISEASES OF THE LARYNX. 

The size varies from that of a pin-head to that of a mass entirely filling 
the cavity of the larynx. The condition is one of epithelial proliferation, 




Dundas Grant's guarded forceps. 

the cells piling themselves nj) on the surface and producing a wart-like 
growth. Papillomata are more common in children and young adults. 

Fig. 262. 




Mathieu's laryngeal snap-guillotine. 



Occurring in a person past middle life, they should always excite sus- 
picion, for, no matter how innocent they ai^pear, they may be the initial 



TUMORS OF THE LARYXX. 651 

stage of a malignant growth, and persons thus affected should be ex- 
amined at regular intervals. Eemoval is generally easy, but thorough 
eradication sometimes very difficult. Some of these growths have seemed 
to disappear under frequent spraying with absolute alcohol. In young 
children a tracheotomy will sometimes lead to their disappearance by 
putting the glottis completely at rest, but recurrence may take place after 
the tube is removed. In other cases it is necessary to perform thyrotomy 
and thoroughly eradicate the masses. 

Fibromata occur next in frequency and belong to a later period of 
life. Their structure is essentially the same as that of fibromata else- 
where, — i.e., one of interlacing connective- tissue fibres containing branch- 
ing cells, with a scanty blood-supply and a hj^persemic mucosa. They 
are usually sessile, and located on the anterior portion of the cords. 
Many of the reported fibromata are thought by pathologists to be 
analogous in structure to oedematous nasal polyi)i. 

Fig. 263. Fig. 204. 





Papilloma of the cord as usually seen. Papilloma covering the laryngeal aperture and 

(Lennox Browne.) attached antenorh . (Grunwald ) 

Cystomata originate from occlusion of a gland-duct or from cystic 
degeneration of a gland-lobule. They occur on the epiglottis, true cords, 
or in the laryngeal ventricles. AVhen on the cords they appear as trans- 
lucent masses, but when located higher up they are more opaque. They 
belong to the middle period of life, and when once removed rarely return. 
The contents are generally of a mucoid nature. Tervaert ^ collected the 
records of ten cases in which the sacs seemed to contain air. Such cases 
have been regarded as congenital enlargements of the sacculus larj^igis. 

Myxomata are often confounded with oedematous fibromata. They 
occur invariably on the cords, may be either sessile or pedicled, and in 
general appearance may resemble either ordinary myxomata. as seen in 
other parts of the air-tract, or papillomata. 

Lipomata are rare. They are regularly attached to the aryepiglottic 
fold, falling thence into the hyoid fossa, where they may expand into a 
considerable size. Both the galvano- cautery and scissors have been 
used for their removal. 

1 Ann. des MaL de POreille, 1898, vol. xxiv. p. 572. 



652 DISEASES OF THE LARYNX. 

Angiomata are also rare. They arise by preference from the vocal 
cord, but have been found on the ventricular bands, epiglottis, and in the 
hyoid fossa. They appear as muriform masses, and are made up of a 
vascular mesh- work held together by connective tissue. 

Adenomata are naturally more common in those localities in which 
glandular sui)ply is abundant, such as the epiglottis and sacculus laryn- 
gis. Lennox Browne believes that all such growths should be regarded 
with grave suspicion, adding that '^the term adenoma maybe a mere 
euphemism for quiet cancer." Some deny that true adenoma ever occurs 
here. 

Enchondromata arise from one of the laryngeal cartilages, prefer- 
ably the cricoid, and are made up of hyaline substance ; though, if 
springing from the epiglottis, there may be an admixture of fibrous 
tissue. They are usually sessile, of irregular outline, and maj^ become 
eroded. 

Lymphomata and colloid growths are mentioned but rarely in the 
literature of laryngeal tumors, and would probably not be recognized as 
such from their gross appearance. 

E VERSION OF THE LARYNGEAL VENTRICLE. — A Condition occasion- 
ally seen in the larynx may here be mentioned, — viz., eversion or pro- 
lapse of the laryngeal ventricle. Though appearing as a tumor, it is in 
no sense a neoplasm, and is mentioned under this heading only as a matter 
of convenience. 

The anatomy of the ventricle has already been mentioned (p. 583). 
Occasionally there is found protruding from its site a fleshy mass looking 
very much like a fibroma, but devoid of the latter' s firmness. It over- 
hangs the true cord and shows some of the symptoms of a true tumor. 
It was formerly supposed to be an actual prolapse of the ventricular 
lining, but more recently it is looked upon as the result of rapid swelling 
or of the entanglement of foreign material in the ventricle itself (Shurly). 
Some cases seem to result from injury. Careful probing will usually 
distinguish it from a fibroma, the only kind of growth with which it 
is liable to be confounded. The symptoms are usually of a mild type, 
being those due to interference with respiration and phonation. Treat- 
ment consists in removal with forceps or snare, though in some instances 
it may be necessary to split the thyroid cartilage and thus gain freer 
access to the deformity. 

MALIGNANT TUMORS OF THE LARYNX. 

Sarcoma. — The relative infrequency of sarcoma in this situation may 
be learned from the figures of Gurlt, quoted by Bosworth. Out of eight 
hundred and forty-eight cases of sarcoma seen in two of the Vienna 
hospitals there was but one of sarcoma of the larynx. During the same 
period sixty-two cases of laryngeal carcinoma had been noted out of a 
total of nine thousand five hundred and fifty-four instances of cancerous 



TUMORS OF THE LARYNX. 653 

affections iu general. Laryngeal sarcoma occurs three times as fre- 
quently in men as in women, and affects middle and later life. Statistics 
show that it develops in women at an earlier age than in men. As to 
its special cause, nothing is known. Various histological varieties are 
found, — spindle- and round-celled, alveolar and giant-celled, — the names 
being given in order of relative frequency in recorded cases. Most of 
such growths arc located on the true cords, though any part of the larynx 
may be affected. All authors note the fact that if the larynx is primarily 
attacked, the tumor seems to confine itself thereto. It does not extend 
to the pharynx, extension in the oi^posite direction being the rule. Ulcer- 
ation occurs later, but erosion of cartilage is rare. 

Symjytoms. — The first symptom attracting attention is generally vocal 
impairment, gradually progressing. As the mass encroaches on the air- 
tract, respiration becomes impeded, and cough is generally present, 
though not, as a rule, annoying. Pain is not often felt, though if the 
epiglottis or i)arts above be involved there is more or less painful 
swallowing. The cervical glands have been affected in about one- 
seventh of all recorded cases, more commonly with the round-celled and 
alveolar forms of the disease. 

Duration. — The duration of a given case cannot be predicted. Some 
l^atients come under observation after comx^laining only a few weeks, 
while others have suffered as many years. The round-celled and 
alveolar forms grow most rapidly. 

Diagnosis. — Without the aid of the microscoj)e it is impossible posi- 
tivelj' to decide in laryngeal growths between sarcoma and carcinoma. 
Ulceration comes later in sarcoma, pain is less, while growth is, as a rule, 
more rapid. Projections from the central mass are more apt to be broad 
and rounded. 

Prognosis. — This is always bad, though collected figures seem to show 
that the outlook for i)rolongation of life is somewhat more favorable in 
sarcoma than in carcinoma. 

Treatment. — This is purely surgical, and will be considered under tlue 
heading of treatment of carcinoma. Xo good results have thus far been 
obtained in sarcoma of the larynx from the use of erysii3elas toxins. 

Caecixoma. — Under the heading of carcinoma of the larynx reference 
is made to those cancers which affect this organ x^riuiarily and not to 
those which invade it from surrounding areas. In regard to the fre- 
quency of malignant disease in this organ, the most accurate ideas are 
based on the figures collected some years ago b}' Sii' Felix Semon,^ when 
unusual interest in this disease was aroused by the illness of the Emperor 
Frederick. From one hundred and seven reporters, statistics of ten 
thousand seven hundred and forty-seven cases of benign and fifteen 
hundred cases of malignant growths of the larynx were carefully coh 

^ Centralbl. f, Lar., 1889, passim. 



654 DISEASES OF THE LARYNX. 

lected. Carcinoma occurs from three to four times as often in men as 
in women. The general principle of heredity as applied to cancer is 
equally i3ertinent here. Cases have been reported in very young chil- 
dren, but most occur from the fortieth to the seventieth year. The 
better classes suffer more than the poor. Many of the patients have been 
voice-users, but nothing definite can be stated as to the cause of this 
special localization. 

The most common form of laryngeal cancer is epithelioma, which here 
presents no special histological features 5 other varieties which have been 
reported from time to time are combinations with adeooma, scirrhus 
(rare), and the encephaloid form. The mixed form with adenoma ap]3ears 
to grow more slowly than the others, and in so far is more favorable for 
operation. Various parts of the larynx may be affected, the left side 
seeming to be the more common starting-point of the growth, that appears 
by preference on the ventricular bands. Other starting-points are the 

true cords, epiglottis, commissures, and 

^^*^^ "^^^- ary epiglottic folds. As long as the 

growth confines itself to the laryngeal 

cavity, the cervical glands are not in- 

>- volved. This sparing of the cervical 

; 11 ' lymph-nodes is due to the peculiar ar- 

^^Z<m' I rangement of the lymx)hatics, not to 

^^ ^ i > ■ their scarcity in the interior of the lar- 

'-^.^^^-^Jjj^ ynx. Even in intrinsic cancer the 

^\,^^^^^ "' glands at the sides of the trachea and 

->^^ bronchi are often invaded. Thiriet^ says 

Carcinoma of the laryux. (Grunwaid.) ^j^^t the ffland most frequentlv involved 

a, ulceration. . , • . • ^i \ ,^ i ^ 

m extrinsic cancer is the one at the level 
of the anterior border of the sternomastoid muscle at the height of the 
space separating the hyoid bone from the thyroid cartilage. 

Symptoms. — The first symi)tom is a huskiness of the voice, which goes 
on to actual hoarseness, weakness, and aphonia. Meanwhile, cough and 
dyspnoea may be added. At first pain appears only on swallowing, later 
intermittently, independent of this function, and finally is constant. It is, 
unfortunately, worse at night, so that the x)atient is robbed of his sleep. 
Appetite fails, emaciation comes on, and finally the characteristic cancer- 
ous cachexia, though the latter is comparatively late and is often absent. 
The relative order of symjDtoms is largely determined by the site of the 
tumor. Some authors mention salivation as a constant feature. Later 
stages are characterized by ulceration and possibly hemorrhage. The 
ulceration is due either to increased cell-proliferation or to attrition of 
affected surfaces, and is accompanied by a foul discharge of mucus and 
muco-pus mixed with cell detritus and necrotic tissue. A peculiar odor 

1 These de Paris, 1889. 




TUMORS OF THE LARYXX. 655 

often accomi)anies this discharge, as in cancer of the pharynx. Finally, 
in the very last stages, the growth may penetrate the laryngeal cartilages 
and appear in the neck as a fungoid mass. Cartilaginous sequestra may 
be extruded, while pieces of the tumor may be coughed uj) or, becoming 
loose, fall back into the air-i^assages. Before this stage is reached, 
tracheotomy may have become necessary to prevent suffocation by direct 
encroachment. Cough is incessant, swallowing almost if not quite impos- 
sible, and the general condition one of the most abject misery. Death 
occurs from exhaustion, insi^iration-pneumonia, suffocation, or rarely 
from hemorrhage due to the erosion of a large vessel. 

Duration. — Three years is practically the limit of life, dating from 
the first appearance of the disease, except in the adeno- carcinomatous 
cases, which are of slower growth, and may continue a Aear or two 
longer. 

Diagnosis. — In view of the terrible nature of the malady and the advisa- 
bility of early operation, recognition of the exact nature of a laryngeal 
tumor becomes a matter of the most urgent imx^ortance. J. X. Mac- 
kenzie^ says that there are ''three principal methods of diagnosis in 
laryngeal cancer. These are in the order of their i^ractical importance 
and usefulness : (1) the naked- eye method, or diagnosis by direct in- 
spection supplemented by clinical phenomena 5 (2) thyrotomy ; and 
finally (3) the microscope. Of the three methods, the second is often in- 
cluded in, and therefore ancillary to, the first." 

This author thinks that surgeons have in recent years relied too much 
on the microscope alone, or rather that in their devotion to it they have 
neglected other and valuable means of diagnosis. Nothing would appear 
more natural than that one should remove a piece of the tumor for exam- 
ination and on the findings of the latter base his subsequent action, and 
this is undoubtedh^ the course most often followed. The objections to 
this procedure are (Mackenzie) that it subjects the patient to the dangers 
of autoinfection at the j)oint of incision and to metastasis at other sites, 
stimulates the local growth of the malignant mass, and is often inconclusive 
and misleading and at times impossible. The removal of a fragment of 
the tumor for examination is strongly condemned by many writers, unless 
the patient' s consent to immediately undergo radical treatment, provided 
the findings demonstrate maliguanc}', be previously obtained. Malig- 
nant tumors here, as elsewhere, do not grow with a regular rate of 
increase. After a period of quiescence they may suddenly start up 
into renewed activity without api^arent cause, and grow so much more 
rai^idly that, if the removal of tissue happens to coincide in time with 
one of these periods of recrudescence, the former is given the credit of 
having caused the latter. This is one of the arguments used to justify 
the position of those who counsel removal of tissue for examination. As 

^ Xew York Med. Jour., September 8, 1900, p. 397. 



656 DISEASES OF THE LARYNX. 

bearing on this point there may be cited the statement of O. Chiari,^ 
whose personal experience was that out of twenty-eight incisions for re- 
moval of tissue, rapid increase of growth was noted only once. In this 
case, which was one of epithelioma on the free edge of the cord, increase 
of growth was noted in five days. Of the danger of autoiufection, how- 
ever, there can be no question. 

As to differential diagnosis, it may be said that some epitheliomata 
resemble papillomata in gross appearance. Moreover, as is well known, 
bits of tissue removed for examination may be superficial and not histo- 
logically representative of the whole growth, so that an opinion predi- 
cated on these superficial portions alone is necessarily erroneous and 
incomplete. Jurasz notes that malignant tumors appear to grow into 
rather than out of the underlying tissue. A snow-white color of the 
growth has been considered evidence of malignancy. In the Transac- 
tions of one of the meetings of the Laryngological Society of London, 
Semon^ is quoted as having said, 'Hhat if one met with a growth of 
particularly snow-white color which at first sight looked like a papilloma, 
but the eminences of which were not nearly so bulbous and rounded as 
in papilloma, but sliar])ly pointed like grasses, that such an appearance 
was extremely suggestive of malignant disease." 

Age is of some value in diagnosis. Thus, below thirty years the mass 
is x>robably not carcinomatous, but after fifty it is probably malignant, 
especially if occurring in a larynx free from previous disease. Pedicled 
growths are more likely to be benign, and all the more so if, after an 
existence of several months, there be no evidence of surrounding inflam- 
mation or infiltration. Hindrance to free movements of the cords is to 
be looked on as suspicious, and the same remark applies in adults to 
recurrence after removal. In this disease there may also be flat ulcers 
with sharply cut edges. 

Eoquer Casadeus ' lays down the following general propositions as a 
guide to diagnosis. (1) In patients of forty years and over all hyper- 
plastic masses on the posterior third of the cords, whether pedicled or 
not, of firm consistency if nodular, if bleeding easilj^, of crescent shape, 
and accompanied by a certain degree of immobility of the parts, lead 
to a strong suspicion of cancer. (2) All vegetations springing from 
the epiglottis or margins of the larynx, of a rosy color, bleeding . easily, 
with a slight infiltration of neighboring parts, should lead (if one 
can exclude syphilis) to a suspicion of cancer. (3) If a piece of 
the growth be removed for examination, it must include not only the 
whole thickness of the tumor, but also some of the surrounding healthy 
tissue. 



1 Arch. f. Lar., Bd. viii. S. 84. 

2 Jour, of LaryngoL, February, 1900, p. 77. 

3 Ann. des Mai. de rOreille, 1900, vol. xxvi. p. 160. 



TUMORS OF THE LARYNX. 657 

Tlie foregoing rex)resent fairly well present views on this difiicnlt 
matter of differential diagnosis. 

AMien adults present tlieniselves with more or less infiltration sur- 
rounding a central focus in the larynx, the question at once comes uj) as 
to differentiation between tuberculosis, syphilis, and malignant disease. 
As regards the former, there are, as has been seen, certain slow forms 
of laryngeal involvement quite different in appearance from typical 
tubercular laryngitis. Under such circumstances one must carefully 
look for evidences of tuberculosis elsewhere, watch the temperature, 
examine any sputa which may be available, and take evidence from a 
wide field before forming an oi)inion. In syphilis the body must be 
carefully examined for stigmata of the disease, due attention paid to the 
previous history, and the patient given the benefit of the therapeutic test 
of the iodides. Here one must guard against the fallacy of diminution in 
the mass, for while it cannot be asserted that potassium iodide causes a 
diminution in the actual cancerous mass, it does often bring about a tem- 
porary reduction of the inflammatory zone surrounding the cancerous 
focus, in a gross sense being part of the tumor. The reduction in size is 
but temporary, and must be given, as evidence, only its due weight. 
Finally, the possibility of symbiosis of malignant growth with either 
syphilis or tuberculosis must always be remembered. The foregoing 
remarks apply particularly to those growths which start inside the larynx 
and present simply as rounded swellings or infiltrations, from which it is 
difficult to remove a fragment for examination. After the ulcerative 
stage has appeared there is found the usual fungating ai)i)earance, with 
swelling of the surrounding i^arts and more or less distortion and loss 
of the usual landmarks. 

Frognosis and Treatment. — Xothing short of surgical intervention 
offers the least prospect of prolonging life, and the matter turns on the 
procedure to be followed in each case. Of late years the opinion has 
been steadily gaining ground that cancer of the larynx is a condition 
calling for oj^eration from without rather than from within. Middlemas 
Hunt believes that ''any one who attacks a malignant growth by the 
endolaryngeal method takes upon himself a grave responsibility, and 
must be possessed of a high degree of manii)ulative dexterity.'' Abla- 
tion of visible masses by means of forceps does not by any means imply 
removal of all the malignant deposit, which may have infiltrated to a 
much greater extent than aj)pears on the surface. Of instruments em- 
ploj'ed for this purpose may be mentioned, in addition to the various 
forceps, etc., previously alluded to, the forceps of Stoerk with various 
distal shapes, and those of Schrotter. All of these have the disadvantage 
of being able to remove only small portions of the growth at each section, 
with all the disadvantages above mentioned as incident to this method. 
Surgeons are therefore obliged to resort to i)artial or entire thyrotomy or 
larvngectomy. 

42 



658 



DISEASES OF THE LARYNX. 



For the removal of malignant growths thyrotomy is most frequently 
indicated, and in order to be successful It must be undertaken very 
early. Xot only must the growth itself be thoroughly eradicated, but 
an area of surrounding healthy tissue must also be taken out. Other 
conditions of success are limitation of the disease and its confinement 




within the laryngeal cavitj^ without involvement of the cervical lymph- 
nodes. The operation is not especially difficult. Even if the patient 
survive the three years' limit (the criterion of perfect success), there 
is great danger of permanent impairment of voice. Mackenzie takes a 
wider view of the applicability of the operation (for the details of which 
the reader must consult treatises on general surgery), declaring it justi- 



TUMORS OF THE LARYNX. 



659 



fiable if the examination of the larynx leave one in doubt as to the 
exact nature of the conditions to be dealt with or fail to define the exact 
limitations of the disease. Enlargement of the cervical glands he declares 
to be no contraindication. Thyrotomy itself may fail to define, either 
by the direct view it afi'ords of the parts or by the opportunity it giA^es 
for digital examination, the exact area affected. Parts seeming to the 
eye to be perfecth' healthy may under the microscope show malignant 
invasion. His general conclusion is that cancer calls for total extirpa- 
tion not only of the larynx but of the lymphatic structures and even 
adjacent cervical tissues. In other words, one should apply to this re- 
gion the same surgical principles which in cancer of the breast and other 
organs have led to such brilliant successes. 

Fig. 267. 




Schrotter's tube forceps, -^^th knives and applicator. 

In presenting the question of operation to the patient the surgeon is 
asked to express an opinion on the i)robable outcome, and this can be 
based only on recorded experience, which it must be confessed does not 
offer a very favorable outlook. The statistics in this field are, unfor- 
tunately, incomi^lete and misleading, as unsuccessful cases have not been 
recorded. Moreover, in some which have been placed on record more 
than one oiDcration has been performed, and perhaps reported as an ad- 
ditional case. Again, the line of demarcation has not been drawn 
between thyrotomy and partial larj^ngectomy 5 hence it is difficult to get 
an accurate idea as to the prospects of success. 

Chiari,-in a statement of personal exi)erience, notes that in the course 
of eleven years, from 1887 to 1898, eighty-three patients came under his 



1 Ann. des Mai. de 1' Oreille, 1899, vol. sxv. p. 250. 



660 DISEASES OF THE LARYNX. 

observation iu whom he felt justified in making a diagnosis of cancer. 
Operation was advised and accepted in twenty-five. Of this latter 
number eight died shortly after thyrotomy, nine of recurrence between 
six and eighty- six months after operation, and eight remained cured at 
periods ranging between one and five years, six of them having passed 
the three years' limit. 

The latest statistics are those of D. Bryson Delavan.^ They are too 
extensive to be quoted in full here. Suffice it to say that they show a 
gradual, though slight, improvement in cases of recent years over those of 
a former period. In total laryngectomy the recoveries (living over three 
years) amounted to six per cent., in partial extirpation to twelve and 
one-half per cent., and in thyrotomy to eighteen per cent. Total laryn- 
gectomies comprise thirty-four cases by six operators, partial laryngec- 
tomies fifty- six cases by eight operators, and thyrotomy fifty cases by 
seven operators. 

From these statistics it is seen that the outlook is not especially favor- 
able, though very recent figures are somewhat more encouraging than 
earlier ones. In each case the patient should have the matter fairly 
stated to him, and his permission obtained to have done whatever may 
seem necessary. Modern surgery has met with some brilliant successes 
in this direction, but the great advance is to come from a more thorough 
cultivation of the art of early diagnosis, on which the result of operation 
so closely dej)ends. Eemoval of the larynx is a terrible mutilation : one 
or two forms of artificial larynx have been devised, but the wearing of 
them is tedious, and the patient speaks in a monotone, though capable 
of articulate speech. In a few instances some fold of tissue above the 
laryngeal site has by a remarkable provision of nature taken on the func- 
tion of a vibrating medium, and articulate whispering speech has become 
possible without any larynx whatever, either natural or artificial. 

It hardly seems necessary to add that the average laryngologist who 
may perform with skill all the usual intralaryngeal manipulations is 
not the one to undertake an excision of the larynx. The rights of the 
patient demand that an operation of such magnitude should be intrusted 
only to a general surgeon thoroughly skilled in all modern technique, 
preferably one who has had some experience in laryngological work, and 
who appreciates the difficulties of this special field of practice. 

1 New York Med. Jour., September 15, 1900, p. 449. 



CHAPTEE XVIII. 

NEUROSES OF THE LARYNX. 

Neuroses of the larynx may be divided into (1) paralysis of sen- 
sation and (2) x^aralysis of motion. The causes in either case may be 
functional or organic. 

PARALYSIS OF SENSATION. 

Under this heading are to be considered anaesthesia, hypersesthesia, 
parsesthesia, and conditions of neuralgia of the larynx. 

AncesfJiesia, or loss of sensation, is due to an imx^airment of function 
of the superior laryngeal nerve, either from alteration of structure at its 
origin, as in bulbar i)aralysis, or from various diffuse cerebral lesions, 
affections of the medulla, locomotor ataxia, or local neuritis from the 
poison of diphtheria. It occurs in minor degrees in long-continued 
catarrhal states, syphilis, and hysteria. It is evidenced then by the ab- 
sence of cough and reflex ; in the more severe forms there is danger of 
accumulation of secretion, food, etc., with consequent choking. The 
prognosis depends on the possibility' of removing the cause. Dix^h- 
theritic and syphilitic cases generally recover under systemic treatment. 
General treatment consists in the administration of arsenic, strychnine, 
phosphorus, zinc, etc., together with the use of the faradic brush, applied 
daily ; the latter should be introduced into the larynx six or eight times 
at each sitting. The other electrode may be placed over the larynx 
externally, or a large flat sponge may be put at the nape of the neck. 
In milder cases the i)lacing of the electrodes one on each side of the 
larynx may sufiice. In the worst cases feeding with the tube is necessary. 

Hypercesthesia depends partly on the natural irritability of the part, 
but more frequently it is directly due to some catarrhal state or is a 
reflex neurosis from a lesion higher up in the respiratory tract or pharynx. 
It is especially noticeable in laryngeal tuberculosis and in carcinoma. 
The rheumatic or gouty diathesis seems to predispose to it, and it may be 
symx)tomatic rather than an independent lesion. The condition is often 
so pronounced that swallowing or even sjieaking causes intolerable j)ain. 
Treatment obviously consists in removal of the cause. Neurotic cases 
require the usual sedatives, such as bromides, valerian, etc., while cases 
with gouty and rheumatic tendencies call resi)ectively for colchicum and 
the salicylates. A careful search should be made throughout the entire 
upi3er air- and food-tracts for a possible lesion which may cause reflex 
irritation, and this should be done before any treatment is directed to the 
larynx itself. In incurable conditions, such as carcinoma and tubercu- 

661 



662 DISEASES OF THE LARYNX. 

losis, the pains may be relieved by the means mentioned under those 
headings. Catarrhal conditions are relieved by sedative inhalations. 

Farcesthesia refers to abnormal but not distinctly painful sensations in 
the larynx, of which there may be an infinite variety. The most common 
are a feeling as of a foreign body, tickling, desire to swallow, etc. Here 
again it should be said that the vast majority of these are referable to some 
condition in the parts above, the reflex irritation being referred to a 
lower level. Foreign bodies often lodge momentarily and then are ex- 
pelled, leaving behind a sore spot, and thus giving the i^atient the feel- 
ing as if the foreign substance were still there. People of nervous tem- 
perament and low vitality, especially hysterical women, make up the 
majority of such sufferers. Treatment should commence with the reas- 
surance of the patient, careful examination should be made to detect, if 
possible, the source of the trouble, sedative inhalations may be used with 
benefit, and the same general tonic measures followed as suggested in the 
preceding section. 

Neuralgia of the larynx has been variously ascribed to gout, rheuma- 
tism, anaemia, malaria, ulcerative processes of various kinds (though 
rare in syphilis), and all acute inflammations. Sometimes no cause is 
apparent, but generally one can be found by patient searching, and each 
will suggest its own proper remedy. If no local condition need attention, 
one may have recourse to those agents which act so well in neuralgias 
elsewhere. Combinations of acetanilid, monobromate of camphor, 
caffeine, etc., are all applicable, and especially aconite or its alkaloid 
may be given in small and relatively frequent doses up to full physiolog- 
ical effect. 

MOTOR NEUROSES. 

Motor neuroses are divided into two classes, — (1) spasmodic and (2) 
paralytic. 

Laryngeal Spasm. — Spasm of the glottis has already been consid- 
ered in its most common aspects under the heading of local inflammation 
causing reflex irritability and in children croupy conditions. The matter 
is further mentioned in the chapter on foreign bodies in the air-tract. 
In addition to all these there is a condition of spasm purely neurotic in 
character, consisting in a closure of the glottis, coming on suddenly, and 
during its persistence shutting off more or less of the air-supply. At 
other times the latter may be normal, but there is a spasm of the muscles 
of phonation. Eespiratory spasm presents certain differences in children 
from that in adults. It is, therefore, advisable to discuss the two con- 
ditions separately. 

Spasm of the Glottis in Children. — In young children the laryn- 
geal structures are all soft and yielding. Eachitis is found to be the 
main underlying condition in patients of this class, but bad hygienic 
surroundings, lack of proper food, and insufficient clothing all contribute 



NEUROSES OF THE LARYNX. 663 

their influence. The exciting cause of an attack may be either local 
irritation, as from a bit of food in the larynx, prolonged crying, exposure 
to cold, pertussis, etc., or reflex irritation, especially from intestinal dis- 
turbances (indigestion, parasites). The teething period is a time of great 
suscei:>tibility. Pressure on the trunks of the laryngeal nerves is in some 
instances a cause, while in others an overgrowth of the lymphoid tissue 
in the nasopharyngeal vault is the x)robable origin of the disease. 

Occurrence. — This form of disease generally occurs during the first 
eighteen months of life, and is far more common among boys. 

Fathology. — The condition is one of spasm of those muscles which 
close the glottis, — namely, the arytenoid, the lateral crico-arj^teuoids, and 
the thyro-arytenoids. A relatively similar result may arise in minor 
degi'ee from the unopposed action of these same muscles owing to paralysis 
of their physiological antagonists, but this is not true spasm. As indi- 
cated under etiology, the spasmodic motor impulse may be a reflection 
of a sensory impulse from various areas or may originate in the nerve- 
centres from malnutrition. In either event it follows the fibres of the 
pneumogastric. 

Symptoms. — The symptoms may show themselves without warning, 
and are more frequent at night. The child suddenly starts up, gasps 
for breath, and, if the attack be prolonged, speedily becomes cyanotic. 
There is the usual insi)iratory stridor, and exj)iration may be attended 
by a sound indicating stenosis of the glottis. The duration of the spasm 
varies, rarelj- lasting, under ordinary circumstances, more than fifteen 
or twenty seconds. Then the muscles relax sufficiently to permit the 
entrance of enough air to sustain life, though the spasm may not entirely 
subside for some time. Death occurs frequently in the stage of apnoea. 
The attack may not be repeated until the next night, or it may come on 
at irregular intervals. In the worst cases the spasm involves the respira- 
tory tract and appears in the hands, feet, and limbs. If the attack be 
often repeated, the child soon shows impairment of nutrition. 

I)iag)wsis. — The absence of fever and cough will differentiate the 
condition from subglottic laryngitis, which is attended by inspiratory 
dyspnoea only and by some secretion. Bilateral paralysis of the abduc- 
tors, with somewhat similar symptoms, is rare in children. Tumors 
more often i^resent evidences of progressive dyspnoea with vocal impair- 
ment. 

Frognosis. — This depends on the age, the sui'ioundings, and the inter- 
val between the attacks. Eeid notes one hundred and fifteen deaths out 
of two hundred and eighty-nine cases. 

Treatment. — This must be directed, first, towards relief from the attack, 
and, second, towards the removal of exciting conditions. Fresh air, re- 
moval of all constricting clothing, semi- recumbent position, drawing 
forward the tongue, cold compresses to the head, and hot applications to 
the feet and legs will all tend to relax the spasm and facilitate respiration. 



664 DISEASES OF THE LARYNX. 

A small dose of morphine and atropine by hypodermic syringe is the 
most efficient medication during the attack. Should the apnoea continue, 
and there be immediate danger of carbonic acid asphyxia, one may pass 
a catheter into the larynx, intubate, or perform tracheotomy. As soon 
as immediate danger is over, the stomach should be emptied by an emetic, 
such as apomorj)hine, ipecac, or similar remedy, and a high rectal injec- 
tion of soapsuds or a dose of calomel or gray powder be given, to be 
followed in four hours by citrate of magnesia. The genital tract should 
be examined, as some of these disturbances may come from vaginal con- 
ditions or a tight prepuce. These measures should be followed by the 
administration of nerve sedatives, such as chloral, the bromides, etc. 
If the attack be only a slight one, chloroform inhalations may cautiously 
be tried. Other remedies which have proved of service are antipyrin, 
physostigma, and drugs of the latter class, and, according to some 
authors, musk seems to be of peculiar value as an antispasmodic. After 
the attack has completely subsided, attention must be x)aid to the general 
health, and tonics, such as iron, cod-liver oil, and the hypophosphites, 
should be systematically given, and special attention paid to bathing, 
clothing, habits, etc. 

Spasm of the Glottis in Adults. — In this condition there is a 
seizure of both constrictors and dilators, the former predominating. 
Undoubtedly most of the cases are of reflex nature, and in adults the 
seizure is rarely fatal. 

Etiology. — The list of causes includes the entrance of food, drink, 
foreign bodies, etc., into the larynx. Mild forms are often seen in the 
intralaryngeal manipulations of ordinary treatment. Eeflex causes may 
be found in any of the mucous membranes of the air-tract higher up, or 
in distant organs, such as the genital tract, alimentary canal, etc. Any 
pressure on the efferent nerves of the part may excite it, and laryngeal 
crises, so called, are met with in some cases of tabes, meningitis, and 
similar conditions. Occasionally syphilitic and tubercular disease of 
the larynx may be accom]3anied by spasms, but here there is generally a 
preceding oedema. 

Sym])toms. — These are of the nature indicated, and occur most fre- 
quently at night and during sleep. The attacks generally last about 
fifteen seconds. There is no nocturnal periodicity of successive attacks, 
as with children. 

Diagnosis. — The discovery of a lesion higher up will explain the 
reflex nature of some cases. Tabes is generally accompanied by other 
symptoms of the disease, such as changes in pupillary reaction, loss of 
knee-jerk, and the characteristic gait. Earely the crisis is an initial 
symptom of tabes, and for a time these cases may puzzle the physician. 
The laryngoscopic image after the attack has passed may reveal a 
succeeding paralysis, and search should be made for a possible diseased 
condition of the nerve-centres or trunks. 



XEUROSES OF THE LARYXX. 665 

Prognosis. — While the attack is very disquieting to the patient, a fatal 
result is rare. In a few instances tracheotomy has been required. 

Treatment. — The patient should be i:»ut on a course of bromides, cold 
bathing, and a good hygienic mode of living. The bath must be used 
with some caution at first, care being taken that it is not too cold. 
Between the attacks the upper air- tract must be treated as each case 
may require. Internal treatment should consist of arsenic, zinc, phos- 
phorus, etc. 

Chorea of the Laryxx. — This is a form of muscular incoordi- 
nation in which there is a momentary closure of the glottis, followed by 
a sudden breaking through of the air Y>^wt uj) in the respiratory tubes 
below. As a result, the child (for most of the cases occur in childhood) has 
a constant barking cough, which, however, ceases during sleep. In the 
milder cases there is no difiiculty in si^eech, though in severe forms it may 
be jerky and uneven. The disease is seen in its typical form in nervous 
girls at the time of the establishment of menstruation, though cases have 
been reported in adults. 

Examination shows a normal larynx, the movements of which are 
perfectly free and unconstrained in the intervals between the attacks. 
When the latter come on, the vocal cords are suddenh^ and sharply 
approximated, to be separated in a second or two by a similar movement, 
and at tliis instant occurs the characteristic cough. The other muscles 
of the body should be carefully watched for choreic manifestations, 
which may occur in j)arts remote. 

Treatment must be directed to the removal of anj* exciting cause of 
spasm in parts above. Internally, the systematic use of arsenic, carried 
to the i)oint of tolerance, as in chorea in general, and hot sedative inhala- 
tions gives the best results. The vapor of hoi^s upon which boiling water 
has been poured is perhaps as ef&cacious as any local sedative. 

The nature of the foregoing malady is somewhat uncertain. Most 
neurologists are indisposed to regard the condition as a true chorea. 
Some laryngologists have looked upon it as an occupation neirrosis, anal- 
ogous to writer's cramj). In some instances the choreic movements seem 
to extend to the resi)iratory muscles of the chest and abdomen, while in 
others they are also manifest in the x)alate. Schrotter, who in 1879 first 
introduced the term laryngeal chorea, regards many of the cases later 
reported under that title as merely instances of nervous cough, and not 
true chorea at all. For the latest exposition of the history and present 
status of the question the reader is referred to a pa^Dcr by A. Onodi.^ 

Dysphonia Spastica. — As the name signifies, the spasm in this variety 
occurs only when an attempt is made to speak, at which time the phona- 
tory muscles are thrown into a spasmodic state. It is sometimes called 
aphonia spastica, speakers' cramp, or stammering of the cords. The 

^ Friinkel's Archiv f. Lar., Bd. x. S. 31. 



666 DISEASES OF THE LARYNX. 

voice sounds like that of one trying to talk during a violent expiratory 
or expulsive effort, as in parturition or evacuation of the bowels. The 
spasm seems especially to affect the tensors of the cords and the respira- 
tory muscles. The condition generally begins with progressive impair- 
ment of clearness of voice, to which the spasmodic character is soon 
added. The closure always affects the ligamentous portion of the glottis, 
while the portion between the arytenoids may remain partially open. If, 
upon the onset of the spasm, the i)atient persist in the attemi)t to talk, 
it may continue until cyanosis is produced, as in varieties of spasm 
already described. Bosworth calls attention to the fact that one cord 
may overlap its fellow and one arytenoid be projected partially in front 
of its opi^osite. 

The cause of this condition has been variously assigned to hysteria, 
over-use of the vocal organs, various reflex influences, and even a central 
lesion. The condition is not a dangerous one, but very embarrassing to 
the sufferer, and treatment is not very satisfactory. Cases due to some 
ascertainable reflex may be cured by its removal. The list of remedial 
procedures includes absolute rest of the voice, galvanism applied to the 
larynx, tonics, and the cold douche to the head and neck. This latter 
efiected a cure in a case of Schech's,^ and massage of the larynx helped a 
case of F. I. Knight's.^ But one case of this nature has come under the 
writer's observation. 

Laryngeal Paralysis. — The motor nerve-supply of the laryngeal 
muscles comes from the pneumogastric, the superior branch sending a 
twig .to the cricothyroid muscle, which receives also a partial supply 
from the inferior branch, the main motor nerve of the larynx. The most 
recent anatomical studies tend to show that the pharyngeal branch of 
the pneumogastric sends motor impulses to the muscle just mentioned 
through a communicating branch known as the middle laryngeal nerve. 
The motor twig of the superior laryngeal also sends some fibres to the 
arytenoid muscle. The superior and inferior nerves of each side com- 
municate with each other both at the back of the larynx beneath the 
pharyngeal mucosa and on the side of the larynx under the ala of the 
thyroid cartilage. 

About the year 1880 attention was called by Semon and Eosenbach, 
working indej^endently, to the fact that in i)aralyses of the larynx the 
abductor muscles were regularly the first and often the only mnscles 
affected from central or from nerve-lesions. This is known as '' Se- 
mon' s law." Some years later Krause asserted that this ai)parent pa- 
ralysis of the abductors was nothing but a state of contraction due to 
irritation of the nerve-trunks or centres of all the laryngeal muscles. The 
discussion on these two views has been long and the literature has be- 

1 Monats. f. Ohren., 1885, S. 1. 

2 Trans. Amer. Laryngol. Assoc, 1889, p. 67. 



^'EDROSES OF THE LAIIY:N^X. 667 

come voluminous. Suffice it to say that the view originally held by Semon 
is the one no^ generally accepted. VThj the abductors more quickh' 
succumb to paralyzing influences is not known. It has been shown that 
there are in the inferior or recurrent nerve separate branches to the dif- 
ferent abductor muscles, but their position in the nerve does not account 
for the condition it is sought to explain, as they are not in the most 
exposed situation. It has also been suggested that the posterior crico- 
arytenoid muscles are exposed to injury from the passage of food and 
air, but this is mere conjecture. The greater frequency of abductor 
paralysis, however, is unquestioned, not only ciinicalh' but experi- 
mentally, for it has been shown that freezing, irritants such as chromic 
acid and inhalation of ether, and post-mortem changes affect the abduc- 
tors first. The exact cause of this is not known. Grabower suggests 
that it may be due to certain peculiarities of the termination of the fine 
nerve-fibrils in the muscles. Another point long disputed is that of the 
origin of the motor fibres distributed through the laryngeal branches of 
the pneumogastric trunk. Thej have been thought to come from the 
ui)per portion of the spinal accessory, but the latest anatomical researches 
throw doubt on this view, and it is now geuerallj^ admitted that the vagus 
receives its motor innervation through its lower filaments from the dorsal 
nucleus in the lower part of the floor of the fourth ventricle. 

For the present status of the discussion concerning abductor j^aralysis 
the reader is referred to an article by Macintyre.^ 

The lesions causing laryngeal paralyses may be central or local. It is 
very hard to demonstrate the connection between cortical lesions and 
laryngeal paralyses ; medullary and bulbar lesions are frequently, how- 
ever, exciting causes. Paralysis also occurs in tabes dorsalis, syringo- 
myelia, tumors, and from the large number of causes, such as pressure, 
trauma, etc., which may affect the branches of distribution of the pneu- 
mogastric or the nerve itself at anj^ point ; hence this list must include 
all varieties of cervical tumors, intrathoracic growths, thickened pleurae, 
aneurisms, consolidated lung, spinal disease, etc. Moreover, aflections 
of the muscles or local neuritis may produce the same result. This neu- 
ritis may arise from toxin-poisoning in any of the bacterial diseases, from 
states of profound blood im2:)overishment, from certain parasitic maladies, 
and from a large number of medicinal substances, especially lead, arsenic, 
copper, frequently alcohol, and occasionally cocaine, atropine, and mor- 
phine. Paralysis also results from the local lesions of tubercle and 
syphilis. It is occasionally a reflex manifestation of pregnancy, disap- 
pearing after confinement.^ 

These various lesions naturally present symptoms in other domains than 
those of the larynx, according to their extent. Thus, one ma}' observe 

^ Jour, of LaryngoL, 1898, vol. xiii. p. 219. 
'' Przedborski, Arch. f. Lar., Bd. xi. S. 68. 



668 DISEASES OF THE LARYNX. 

accompanying disturbances of the facial nerve causing paralysis of the 
face, of the auditory giving rise to deafness and giddiness, of the glosso- 
pharyngeal producing anaesthesia of the pharynx and larynx and paresis 
of the pharyngeal muscles with dysphagia, palatal paralysis causing 
regurgitation of food into the nose, speech defects, etc. If the hypo- 
glossal nucleus be involved, paralysis with atrophy of the muscles of 
the tongue may occur. 

Diagnosis of such a condition must be made from a study of the asso- 
ciated symptoms, which will locate the lesion with reasonable definite- 
ness. It need hardly be said that unless the central lesion be due to 
syphilis, in which instance therapy may lead to a diagnosis of the dis- 
ease, the prognosis is hopeless. 

SPECIAL PARALYSES. 

Paralysis due to affections of the pneumogastric trunk or nucleus 
manifests itself in the same way as paralysis of the terminal branches, 
and does not require separate consideration. 

Paralysis of the superior laryngeal nerve is followed by a loss of sensation 
in the mucous lining of the larynx, and, owing to its distribution to the 
cricothyroid and arytenoid muscles, occasions a loss of tension in the 
-p cords and a lack of approximation in their 

posterior portion. This condition has been 
observed after diphtheria, typhoid fever, en- 
larged glands beneath, the angle of the jaw, 
and trauma. The great and immediate 
danger is the entrance of food into the larynx, 
causing suffocation, and later foreign-body 
pneumonia. This danger is even more im- 
minent if the recurrent nerve be also affected. 
If both cricothyroids be involved, the cords 
Bilateral paralysis of superior lar- ^i^ ^^ relaxed and prcscut a Avavy Outline 

yngeal nerve. (Porcher.) ,.^. ^^^^ -r-^ -. .-, • -• 

(Fig. 268). If both superior nerves be com- 
pletely paralyzed, the glottis is divided by the ai:)proximation of the 
tips of the vocal processes. Bosworth says, however, that he ' ' knows of 
no lesion whicb will produce this curious appearance." 

The diagnosis is made by the mirror's showing the characteristic 
glottic picture and by the absence of sensation on probing. The prog- 
nosis is unfavorable unless the lesion be due to diphtheria or some toxic 
influence the effects of which may gradually wear away. Treatment 
consists in the administration of strychnine, the use of electricity, 
massage, tonics, and, in bad cases, feeding with the tube. 

Paralysis of the inferior laryngeal nerve (recurrent paralysis) is one of 
the forms most frequently seen. It will be remembered that, with the 
exception of branches of the superior laryngeal to the cricothyroid and 
arytenoid muscles, the entire musculature of the larynx is supplied by the 




NEUROSES OF THE LARYXX. 669 

recurrent nerve. Any lesion, therefore, of this nerve is followed by 
partial or complete loss of motion on the affected side, for in such a 
condition the partial supply of the cricothyroid from another source is 
without avail (Fig. 269). 

Etiology. — The paralysis may be due to a central lesion, but more com- 
monly to a tumor pressing on the course of the nerve. The list of such 
growths is headed by aortic aneurisms and thyroid enlargements, but 
any intrathoracic growth may act in the same way. Certain cases are 
referable to the terminal neuritis following various fever poisons, diph- 
theria, the exanthemata, and influenza. Occasionally a mild type of 
the condition has followed an acute catarrh. 

Pathology. — Degenerative changes occur in the nerve, beginning with 
granulation and iatty degeneration inside the neurilemma, followed by 
disappearance of the contents and by shrinkage. As a result of the 
trophic disturbance there ensues an atrophy of the affected muscles. 

Fig. 269. Fig. 270. 





Right recurrent paralysis; i)osition of Bilateral recurrent laryngeal paralysis, 

cords in deep inspiration. Black perpen- (Porcher.) 

dicular indicates median line of rima 
glottidi>. (Porcher.) 

Symptoms. — If the paralysis be confined to one side, the voice becomes 
at first weak and later hoarse, vocal range is limited, and conversation 
fatiguing. The affected cord is generally in the so-called cadaveric 
position, — that is, midway between adduction and abduction, — with con- 
cave edges. After a while the sound cord crosses the median li?ie to 
meet its fellow. As a result, the voice may gradually become clear 
unless undue demands be made upon it. In i)honation, the arytenoid 
cartilage of the sound side passes slightly in front of its opposite. Dysp- 
noea is absent. 

When both nerves are invoh'ed the voice is entirely lost, and only by 
the greatest effort is even a whisper produced. There is no true dj spncea, 
though the breathing may be somewhat stridulous from the approxi- 
mation of the tips of the arytenoids. 

Diagnosis. — Diagnosis is made from the i)osition of the cords. Care 
must be taken not to confound this form of paralysis with that due to 



670 DISEASES OF THE LARYNX. 

loss of power in the adductors, in wliicli both cords are widely separated^ 
owing to the unopi)Osed action of the abductors. In the latter condition 
the cords are drawn to the sides of the larynx or, if less widelj^ sepa- 
rated, show jerky movements on attempted phonation. The rima glot- 
tidis may be oblique. 

Prognosis. — This depends on the nature of the cause and the possi- 
bility of its removal. I^euritis from certain fever j)oisons may easily be 
overcome. Cases due to aneurism, tumors, or central lesions vary ac- 
cording to changes in the exciting cause. If no improvement result in 
from six to eight months, the condition will probably be permanent. 

Treatment. — All acute catarrhal conditions should be treated, and for 
the neuritis of fevers and diphtheria the usual tonics given, especially 
combinations of strychnine with phosphorus and arsenic. Aneurisms 
call for the iodides. Electricity keeps up the tone of the muscles until 
the restoration of nervous stimulation. On general princii)les it may 
here be said that faradism is to be preferred if it will cause muscular 
contraction ; if degeneration has gone so far that it will not, the inter- 
rupted galvanic current should be tried. One electrode should be placed 
on the nape of the neck and the other over the front of the larynx, or 
one electrode can be put inside the latter and an endeavor made to stimu- 
late individual muscles. This is not difficult and, under cocaine, not 
painful. 

Paralysis of the Adductors. — Paralysis of the interarytenoid mus- 
cle most often occurs from simple catarrhal causes, or it may form one 
feature of a more composite paralysis. The cords show between the 
arytenoid cartilages an irregular gap due to their lack of approximation. 
According to the size of this triangular opening there is more or less 
aphonia. Treatment is along the lines previously indicated. Catarrhal 
cases generally promptly recover. 

Unilateral adductor paralysis is very rare, and much doubt exists as 
to correctness of diagnosis in some of the reported cases. Hysteria and 
lead-poisoning are the causes commonly assigned. The main symptom 
is loss of voice in a varying degree, according to the quantity of air- 
waste. Examination shows the cord in a state of extreme abduction, and 
the picture ma^^ be hard to distinguish from recurrent paralysis. One 
must also exclude swelling of the crico- arytenoid joint, and the beginner 
may mistake for paralysis an overhanging and inflamed ventricular band. 
The prognosis depends on the cause, and the treatment is as before out- 
lined. 

True Ulateral adductor paralysis rarely occurs. The cases reported 
under this heading are generally due to hysteria, in which there is a 
functional impairment without true paralysis. A larynx thus affected is 
styled by some writers an hysterical larynx, though there seems to be 
no intrinsic reason why the conventional list of causes of general laryn- 
geal paralyses should not be operative here. Other writers regard this 



NEUROSES OF THE LARYNX. 



671 



as a separate variety, giving to the hysterical larynx the name of hys- 
terical aphonia. The appearance of the cords suggests to some extent 
that described under the heading of double recurrent paralysis, in that 
there are an imperfect coaptation of the cords on attempted phonation, 
air- waste, and j^artial or complete loss of voice. There is, however, no 
loss of true respiratory movement, — i.e., no absolute lack of motion. 
Another point to be borne in mind is the fact that, although patients 
cannot carry on conversation in ordinary tones, they can speak in a 
measured, emphasized, singsong way, and can in some cases sing fairly 
well ; or, on the contrary, as in a case reported by Porcher, they can 
converse well, but are unable to sing or to preach and read a service. 
Careful examination should be made in these cases for other manifesta- 
tions of hysteria. The prognosis is foirly good, but relapses are frequent. 
Treatment is as before outlined. Sudden cold affusions to the neck have 
benefited some of these patients. 

Unilateral paralysis of the abduetors is the most common of the motor 
neuroses, but its cause is often undiscoverable. It may give no symp- 



FiG. 271. 



Ftg. 272. 





Paralysis of the interarytenoideus muscle. 



Unilateral adductor paralysis ; position of 
cords in attempted phonation. 



toms whatever, and be discovered only during a routine examination, 
which shows the cord immovable in the median line. Many cases are 
referable to an aneurism or intrathoracic growth, but the majority to a 
central lesion, and the Eontgen rays will sometimes solve the mystery of 
their origin. The remarks previously made as to prognosis and treatment 
apply equally well here. 

Bilateral Paralysis of the Abductors. — The true nature of bilateral 
paralysis of the abductors has been much discussed. The muscles affected 
are the posterior crico-arytenoids, which separate the cords and are in con- 
stant respiratory activity, though the movements of the cords in quiet 
breathing are not always evident to the eye. These muscles are situated 
in a relatively exposed portion of the larynx. From these reasons, and 
perhaps from a special proclivity not yet understood, they seem to suffer 
damage niore often and more easily than the adductors. The same gen- 



672 DISEASES OF THE LARYNX. 

eral causes apply here as in otlier forms of paralysis. Examination 
shows the cords in j)ractically the phonatory position, and the voice, 
therefore, in ordinary conversation is but little, if at all, affected. In 
some instances only the anterior portions of the cords are approximated, 
and dyspnoea and stridor are present, both more marked in inspiration 
and during sleep. Forced inspiration, as during severe exertion, is very 
difficult. Paralysis of associated tensors, and possibly of the interary- 
tenoid, may give a triangular appearance to the glottis, the base being 
posterior. A condition somewhat lesembling this in objective appear- 
ance is that due to adductor spasm, but in the latter condition the cords 
are not held rigidly ; they waver more or less, so that the amount of 
adduction is constantly varying ; in paralysis the cords are fixed. In sleep 
the spasm relaxes, but in paralysis the stridor becomes more pronounced. 
Prognosis. — The condition is a grave one, as suifocation is liable to 
ensue, and patients must be warned of the gravity of the situation as soon 

as the exact nature of the neurosis iS evident. 
Fig. 273. In some cases of rapid development the wear- 

ing of a tracheotomy tube has been followed 
by recovery, but it is obvious that these were 
due to some cause not necessarily irremediable. 
But little hope can be held out if the condition 
has lasted over several months, owing to mus- 
cular degeneration and possible changes in the 
crico-arytenoid joint. The condition may 
show itself suddenly, and, unless immediate 
relief is at hand, death ensues from closure of 

Bilateral abductor paralysis ; ^^^ p-lottis duC tO the UUOppOSCd actiou of the 
position of cords in deep inspira- "^ 

tion. adductors. 

Treatment. — The danger of suffocation re- 
quires the insertion of a tracheotomy tube, which may have to be worn 
throughout life. The proposal has been made to excise the vocal cords. 
Aphonia is, of course, the result in either case, but if the latter plan be 
followed the tube can in time be removed. Excision of the cords has 
its advocates and detractors. Section of the recurrent nerve, so as 
to allow the retraction from the median line to the cadaveric position, 
has been suggested and in one case successfully performed.^ Various 
adjuvant topical measures may give some relief. 

Fardlysis of the Tensors of the Vocal Cords. — The most frequent variety 
of myopathic paralysis is that of the internal tensors, the internal thyro- 
arytenoid muscles, and is known as paralysis of the tensors of the vocal 
cords. These muscles lie immediately beneath the cords, and in one sense 
form a part of them. Yocal strain and local inflammation from any 
cause directly affect them. The paralysis is usually but partial. 

^ Geronzi, La Riforma Med., Palermo, July 6, 1899. 




NEUROSES OF THE LARYXX. 673 

Symjytoms. — These are connected chiefly with the voice alone, which, 
according to the severity of the affection, becomes weakened, hoarse, or 
whispering, or there may be complete aphonia. Often the conversational 
voice is scarcely affected, and the difficult}' becomes manifest only on the 
patient's attemi:)ting a carefully modulated exertion, as in singing, when 
an impairment of range may be the most prominent feature. 

Diagnosis — The appearance of the glottis varies according as one or 
both cords are involved. The chink will have the form of a half or full 
ellipse, the edge of the cord being concave from the bellying upward by 
the current of air from below. This elliptical area extends from the 
anterior commissure to the posterior, but that of cricothyroid paralysis, 
it will be remembered, stops posteriorly at the vocal process. More- 
over, the vocal bands become cord-like instead of appearing flat, as under 
normal conditions. 

Prognosis. — This depends on the possibility of giving the vocal organs 
complete rest. If this can be done recovery will generally follow in a few 
days. Caution must be given not to attemi^t 
to treat these cases too energetically, especially 
those due to vocal strain. What they need is 
)^est, and if their restoration to normal func- 
tion is sluggish, stimulating applications, such 
as muriated tincture of iron and glycerin in 
equal parts, or weak silver nitrate solutions, 
may be given. The faradic current, applied 
by means of a wet cotton pledget on a laryn- 
geal applicator, answers well. Internally, the 
familiar combination of strychnine, arsenic, 
and phosphorus may be given, with cold baths, 

^ ^ Paralysis of right internal tensor. 

massage, and the usual measures employed (Porcher.) 

to restore imi^aired nerve-tone. 

In addition to the foregoing definite forms of paralysis there are vari- 
ous combinations of them, so that the laryngeal image is often a puzzle 
on first inspection. The complicated musculature of the larynx and the 
various resultant aj^pearances of the rima giottidis must be studied in 
each case. 

Laryngeal Vertigo. — In 1876 Charcot^ described a series of cases 
in which there occurred a spasm of the larynx followed by sudden loss 
of consciousness, to which he gave the name '^laryngeal vertigo." A 
further study of the condition has proved the incorrectness of this term. 

The attacks are somewhat peculiar in that a person feeling perfectly 
well is seized with a sudden tickling in the larynx, becomes unconscious, 
and may fall, but, if he falls, almost immediately gets up and goes about 
his affairs as if nothing had happened, and apparently is not much the 




^ Compte rendu de la Soc. de Biol, de Paris, 1876, p. 336. 
43 



674 DISEASES OF THE LARYXX. 

worse for his unusual experience. For some years the disease was looked 
upon as a rare condition ; the literature of the last five years has, how- 
ever, placed it outside the category of rare diseases, for many cases have 
been reported. In 1896 Getchell ^ was able to collate seventy -seven in all, 
and there are others on record since that time. 

Etiology. — ^o one set of causes can be assigned. In many cases the 
larj^nx has apparently been in an absolutely healthy condition. Various 
abnormal states of the air-tract have been recorded. In many of the 
cases thus far reported some manifestation of the neuro-arthritic diath- 
esis was seen. 

The main interest centres about the theory of nerve disturbance em- 
ployed to account for the phenomena observed. The affection has been 
called laryngeal epilepsy, and some cases have been attended by several 
of the characteristics of this malady. That true laryngeal epilepsy is 
possible is shown by the case of Sommerbrodt, ^ who in 1876 reported a 
case of a patient with a pedunculated laryngeal polyj), who suffered from 
true epileptic crises which x)ermanently ceased upon removal of the 
growth. It is interesting to note that this same patient had fifteen years 
before a short series of epileptic attacks which were referred to a cicatrix 
on the dorsal surface of the right hand. 

The theory generally accepted is that propounded by McBride,^ who 
based his opinion on experiments in which, unknown to himself, he had 
been anticipated hj Weber in 1851. He found by sphygmographic tracings 
that during forced expiration with closed glottis not only did the pulse 
become much weakened, but that the tracing showed a rapid and con- 
tinuous diminution of the upstroke. From this he reasoned as follows. 
The acts of coughing, hearty laughter, etc., consist of a deep inspiration 
followed by attempted expiration with closed glottis. In laryngeal 
vertigo, however, the closure of the glottis is complete, and the whole 
expiratory effort is felt through the air contained in the lungs, by the 
alveoli, the large blood-vessels in the thoracic cavity, and the heart 
itself. As a result, syncope or a tendency to syncope is produced,. and 
almost at the same minute the sx)asm of the glottis relaxes and the attack 
is over. 

The relation of the condition to asthma is of particular interest. 
This has been studied by Moncorge,^ who reports nineteen cases, all but 
one of which were asthmatic. It is not surprising to find laryngeal 
vertigo, or ictus, as it is sometimes called, in asthmatics, for ictus is 
nothing but a laryngeal spasm, and asthmatics are spasmodics. Again, 
ictus may present itself as a latent form of asthma, but, according to 
present views, should be considered rather as parasthmatic. 

^ Boston Med. and Surg. Jour., November 5, 1896, p. 466. 

2 Berlin. Klin. Woch., September 25, 1876, S. 563. 

3 Edinburgh Med. Jour., March, 1884, p. 790. 

* Ann. des Mai. de 1' Oreille, 1900, vol. xxvi. p. 129. 



NEUROSES OF THE LARYXX. 675 

Symptoms. — The outlines of a seizure have already been presented. 
Xiel,^ who accepts the theory of reflex cerebral inhibition set uj) by irri- 
tation of the endings of the sui)erior laryngeal nerve, divides the cases 
into three classes, according to the degree of inhibition. 

1. Momentary vertigo with a sudden mental blank, coming on and 
passing off so suddenly that the patient is scarcely conscious of it. 

2. Loss of consciousness of some definite duration, say five or six 
seconds, the patient falling down, but quickly rising and going about his 
affairs as if nothing had happened, is characteristic of true laryngeal 
ictus. These attacks are generally ushered in by a ''sense of tickling in 
the larynx, provoking some outbursts of sj)asmodic cough and immedi- 
ately after the loss of consciousness, with redness of the face and some- 
times i)artial epilei)tiform convulsions'' (Charcot). 

3. Sudden death. Undoubtedly some of these cases help to make up 
the large category of sudden deaths from unknown causes. This is a rare 
occurrence, but it does occasionally happen.'^ It has followed severe 
blows on the neck and cauterization and other instrumentation in the 
larynx. In the stage of ictus these cases do not present any evidence of 
dyspnoea. Xiel admits that patients afi<ected with grave organic maladies 
of the larynx, such as malignant tumors, tuberculosis, syphilis, stenosis, 
etc., suddenly die. He explains this fact by assuming a theory of the 
existence of a ''cumulative irritation." This finally becomes so great 
that there is a sudden explosion upon the sensory nerves of the larynx, 
a corresponding reflex upon its motor filaments, a cessation of breathing, 
and a fiital result. 

Diagnosis. — Many cases are mistaken for epilepsy, but there is no 
frothing at the mouth, biting of the tongue, involuntary micturition 
(though one instance of the latter has been reported), and subsequent 
mental impairment, as occur in true epilepsy. 

Prognosis. — In spite of the many mild cases of the affection, its occur- 
rence is always a matter of concern. Special precautions should be 
observed in reference to the emj)lo3'ment of local anaesthesia of the air- 
passages before surgical intervention in patients supposed to be liable 
to this special neurosis. 

Treatment. — This should be directed to the general condition of the 
nervous system. The usual combinations of iron, quinine, arsenic, and 
zinc should be exhibited. Strychnine is, according to Bosworth, contra- 
indicated, but hydrotherapy benefits in most cases. Careful search 
should be made through the upper air-tract for causes of possible irri- 
tations productive of spasm. The recurrence has been broken up bj' 
the cure of an hypertrophic rhinitis and the removal of an elongated 
uvula and other causes of irritation. 



1 Ann. des IMal. de F Oreille, 1899, vol. xxv. p. 161. 
* Schadewaldt, Arch. f. Lar., Bd. v. S. 246. 



CHAPTER XIX. 

DIPHTHERIA. 

Diphtheria is an acute infectious, contagious disease, having its 
local manifestations by preference in the upi)er air-passages, but it may 
appear on any mucous membrane, at any mucocutaneous junction, on 
skin deprived of its epithelium, or on wounds. In the light of present 
knowledge the name should be restricted to ^Hhose cases of sore throat 
in which a false membrane is found, and in which a culture taken 
from this membrane or near it shows the i^resence of the bacilli of diph- 
theria, or to those cases in which there is a x^rofuse nasal discharge, a 
culture from which shows the presence of these organisms" (McCollum). 
This caution cannot be too strongly insisted on. Such a term as diph- 
theritic sore throat should most emphatically be given up, for, while it 
does not mislead the physician, it often lalls the laity into a false sense 
of security and leads to deplorable results. So also the term membranous 
croup falls under the ban. The experience of recent years has conclu- 
sively shown that practically all cases of laryngeal stenosis due to false 
membrane are the product of the bacilli of diphtheria, and that while 
various other micro-organisms may give rise to membrane formation, the 
latter is rarely sufficiently dense and thick to cause respiratory danger. 

Etiology. — Perhaps no disease in the whole range of bodily ills has 
from the very earliest times been more carefully studied than dii)h- 
theria. All writers in all ages have dwelt upon the high potency of its 
contagion. The establishment of the germ theory of disease concentrated 
ideas as to the nature of its exciting cause, but it was not until the 
year 1875 that Klebs was able definitely to isolate the bacillus of the 
disease. His views did not meet with general acceptance till 1883, but 
in the year following they were confirmed and amplified by Loftier. In 
1888 Eoux and Yersin were able not only to experimentally rei)roduce 
the disease, but succeeded in inducing in animals the paralyses and other 
toxic manifestations which had always been matters of clinical observa- 
tion. From this period dates the present conception of the exact etiology 
of this affection. The great majority of physicians now accept the fore- 
going views, believing that diphtheria is caused by the Klebs-Loffler 
bacilli, and by them alone, and from this stand-point the present chapter 
is written. 

The old idea of diphtheria without membrane is now pretty well 

abandoned. It is not always possible to locate the membranous deposit, 

which is not uniformly confined to areas open to inspection, and cases 

have been seen which resulted fatally, with every symptom of toxic sys- 

676 



DIPHTHERIA. 677 

temic poisoning, in whicli autopsies have shown only minute mem- 
branous patches. 

It is quite possible that cultures taken from the mouths of healthy 
persons who have been brought in contact with diphtheritic cases may 
show the presence of the bacilli ; but such persons are not to be regarded 
as having dii)htheria, though it is possible that, by careless exi)ectoration, 
kissing, etc.. they may be the carriers of contagion to others. So also not 
every case of laryngeal diphtheria presents visible membrane, nor are 
culture exx^eriments always positive ; yet autopsies in these same cases 
have revealed the existence of the malady, and in some instances bits of 
membrane have been coughed uj) during life. 

The BaciUus. — The Klebs-Loffler bacillus has about the length of the 
tubercle bacillus, but twice its thickness. Atyx^ical forms are not un- 
common, some having a granular a^^pearance and a club-shaped enlarge- 
ment at one or both extremities. Earely the whole bacillus may as- 
sume a curved shape ; the size may also vary greatly, and the outline is 
generally irregular. Certain well-deiined si^ots may be brought out along 
the axis bj' staining with the Loffler alkaline methyl-blue solution. 

Culture Test. — For practical cliDical purposes the culture test is the 
one usually made. In nearly all our large cities there are either municipal 
or private laboratories to which the j)ractioner who is not a bacteriolo- 
gist may send the culture outfit after it h^is been inoculated. The outfit 
consists, in its simplest form, of two tubes. The smaller one contains a 
sterilized swab made by winding a bit of cotton around the end of a stiff 
wire, the tube being plugged with a stoj^i^er of the cotton, and the whole 
sterilized by heat. In a larger tube is a bevelled layer of a culture-medium. 
That used by the Xew York City Health Board at present has the follow- 
ing composition : beef serum, three parts ; nutrient bouillon (containing 
one per cent, of glucose), one part. The test is considered unreliable if 
an antiseptic has been used in the mouth within two hours of the inocu- 
lation. The swab is withdrawn from the tube, rubbed over the site of 
the diphtheritic deposit, and then smeared carefully and thoroughly over 
the culture-medium in the larger tube, the latter being inverted so that 
no contamination settles in it while the test is being made. The tube is 
then restoppered and returned to a collecting station, whence it reaches 
the laboratory and is placed in a thermostat at from 33° to 37° C. over- 
night. The results are generally determinable by noon of the next day. 
and in cities a notice is mailed to the physician. Of course, such a test 
is not always necessary, for there are manj- cases of dii^htheria in which a 
single inspection of the throat is quite sufficient to establish the diagno- 
sis ; but, on the other hand, if one accepts the definition of the disease as 
laid down in the opening paragraphs of this chai^ter, there are doubtful 
cases in which one's own experience may lead him to decide in favor of 
or against a diagnosis of dii^htheria, and in which a bacteriological diag- 
nosis alone can lead to positive conclusions. Many epidemics of so-called 



678 DISEASES OF THE LARYXX. 

simple sore throats have doubtless been due to mild, thougli unrecog- 
nized, forms of diphtheria. This matter will be alluded to farther on. 

Predisposing Causes. — While the disease may attack adults, the vast 
majority of cases occur in early childhood. Infancy, however, is to some 
extent exempt. Shurly enumerates as causes of this exemption, first, the 
slight opportunity for infection ; second, the antitoxic iDroperties of the 
blood of infants, as proved by several observers ; and, third, the absence 
of catarrhal conditions of the upper air-passages. Diphtheria occurs at 
all seasons, though less often in the summer, perhaps for the reasons that 
the comparatively out-door life at this period and the free ventilation of 
living-rooms by open windows and doors render the conditions less favor- 
able for the propagation of the poison. Diseases of the upper air-pas- 
sages offer favoring conditions for the malady, especially enlargement of 
the faucial and pharyngeal tonsils, for the diseased cryjits of these struc- 
tures furnish excellent culture- media. So also are to be included in the 
list of predisposing causes neglected oral hygiene and the depressing 
effects of other diseases, especially the exanthemata. 

Concerning the effect of bad hygienic surroundings, and especially 
defective drainage, it may be said that, while all these conduce to attacks 
of ordinary sore throat, and thus furnish a suitable soil for the propaga- 
tion of all sorts of pathogenic micro-organisms, they do not directly 
originate diphtheria. Strict isolation and modern hygienic methods will 
check an epidemic anywhere. The attendance at school of children suf- 
fering from mild but overlooked attacks of the disease is a common 
method of disseminating it ; a similar result follows the resumption of 
school attendance by children who have convalesced and appear per- 
fectly well, but in whose mouths the germs yet linger. Ei)idemics have 
arisen in new communities where it has been impossible to trace the 
source of infection. McCollum says that '^it is now generally considered 
that imperfect drainage and unsanitary conditions should not be consid- 
ered important factors in increasing the frequency of this disease." 

The disease is often spread by milk contamination and by infection 
from various domestic animals subject to it. Most cases of so-called 
diphtheria in the lower animals are due not to the Loffler bacillus, but 
to other organisms. The period of incubation varies from a few hours to 
fourteen days (Jacobi), according to the receptivity of the system, the 
average being probably from four to seven days. A patient seldom 
suffers from a second attack within a short period, the cause of this 
immunity being, according to Park, but imperfectly understood. 

Fatliology. — Diphtheria may be looked upon as essentially a local dis- 
ease producing a poisonous material which is absorbed into the cir- 
culation and causes the characteristic symptoms. Most cases begin in 
the throat, where the germ first makes impact and where the condi- 
tions are especially favorable for its development. The coexistence of 
heat, moisture, bits of decomposing food, organic debris, etc., affords 



PLATE XITI. 




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if <iiiiluh.ri;i bacilli on airar. ■ 120 
diameters. 



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diameters. 




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Colonies of diphtheria bacilli on agar. Actual 
size after eighteen hours" growth. 



Characteristic diphtheria bacilli, showing 
irregularit.v of form and staining. 




iiiuirt' uutlit. Box. sterile swal', and tulif ci lumKi-serui 



DIPHTHERIA. 679 

opportunities for the development of the bacillus. A false membrane is 
formed oh the tonsils, faucial pillars, uvula, palate, or pharynx, and may 
extend in various directions. As a rule, it is of a grayish- white color, 
spreading from the original deposit^ and so adherent that its forcible de- 
tachment leaves a bleeding surface. Sometimes it is of a milky-white 
color and for a while can be removed without bleeding. It forms first in 
the superficial layers of the mucosa, gradually extending to the deeper 
portions. It must be remembered that there are many false membranes 
due to various causes and not characterized by a specific germ, but by a 
collection of germs ; so that, as before stated, the mere api)earance of a 
false membrane is no sure sign of diphtheria. The Klebs-Loffler germ, 
when present, is more a-pt to be found in the superficial layers of the 
exudate, while the various other organisms — stai)hylococci, streptococci, 
etc. — are more abundant in the decider layers, though found in all. 

The membrane may extend to the nasopharynx and the nose. From 
the profuse nasal discharge which generally characterizes the latter form 
there may be an infection of the eyes causing intense conjunctivitis, 
swollen lids, and at times a membranous dei)Osit on the conjunctiva. 
False membrane in the nose occurs by i)reference on the turbinated bones ; 
the middle ear may become involved by extension through the Eustachian 
tubes, and downward extension may occur, even into the finer ramifica- 
tions of the bronchial tubes. Of internal organs, the poison most com- 
monly impresses itself on the kidnej'S, which are enlarged, with swollen 
cortex and degeneration of the epithelial lining of the convoluted tubules. 
The heart often shows evidences of fatty and granular changes. The 
latter are not especially noticeable to the naked eye, though easily re- 
vealed by the microscope. Xerve degeneration is very common, the 
cervical lymph-nodes are regularly enlarged and tender, and the blood 
shows a leucocytosis which progresses and diminishes with the course 
of the disease, and is, in a general way, an index of the gravity of the 
situation. The red cells are diminished in number and in haemoglobin 
percentage, and hemorrhages in the skin, mucous, and serous membranes 
are possible. 

The Toxin. — As a rule, the growth of the bacilli does not extend be- 
yond the site of inoculation, but the toxin there produced is taken up 
by the circulation. Park notes that the bacilli may find conditions favor- 
able for growth, but not for toxin production. It is doubtless owing to 
this fact that there are some cases of abundant membrane formation with 
but few constitutional symptoms. 

Injection of toxin in animals will produce all the symptoms of the 
disease except the membrane formation. Various views are extant as to 
the exact nature of the toxin. Some have regarded it as an enzj-me, 
others as a toxalbumin, assigning it to the class of globulins. Its exact 
chemical composition is still a matter of conjecture, as no definite 
analvsis has been made. Lennox Browne holds that the toxins do not all 



680 DISEASES OF THE LARYNX. 

originate in the membrane, nor do the albumoses (resulting from the 
action of the enzyme on the body proteids) merely accumulate in the 
tissues ; but probably the digestion of the body proteids by the action of 
the enzyme absorbed from the membrane forms the toxins. 

Symptoms. — These may manifest themselves rapidly or slowly. All 
variations are found, from a prodromic period of general malaise with a 
non- distinctive sore throat up to a fulmination of symptoms which may 
prove fatal in twenty-four hours from the initial outbreak. Ordinarily 
the patient (usually a child) complains of sore throat, which, on inspec- 
tion, appears hypersemic or may present a patchy discoloration. The 
lymph -glands at the angle of the jaw may at this period be somewhat 
swollen and painful, and swallowing is rather dif&cult. The general 
symptoms are lassitude, stiffness of the muscles, especially about the 
neck, nausea, vomiting, and constipation, but the initial fever is not high. 
The force of the symptoms at this period is measured by the virulence of 
the infection. The younger the patient the more likely is the onset to be 
sudden. 

In the presence of such a history as the above the physician will 
naturally at once examine the throat. Incidentally it is to be borne in 
mind that the initial throat symptoms of diphtheria are often not so 
severe as those of a simple lacunar tonsillitis. Inspection commonly 
shows a general reddening, with perhaps on the tonsil a small grayish 
or whitish-gray patch which quickly enlarges, or there may be different 
spots which coalesce. Extension of the membrane is apt to be along 
the faucial pillars, palate, and uvula. False membrane in the latter 
situation is far more common in diphtheria than in the various 
membranous deposits mistaken for it, which are generally on the con- 
vexity of enlarged tonsils. Initial symj)toms may appear in the 
larynx in the form of stridulous breathing and cough, with evidences 
of more or less obstruction, or the larjmx may become involved later by 
extension or secondary infection, the latter occurring about the seventh 
day. Extension of the membrane in other directions, as above indicated, 
will give characteristic local symptoms. The thickness of the fibrinous 
deposit in any of these situations varies from a thin film to a dense, hard, 
and thick membrane. It grows softer as the case progresses, and may be 
detached. Normally, detachment begins at the edges, which curl up, and 
the i^atch thus peels off. There is an increase of pharyngeal mucus, 
that, owing to the local conditions in the throat, is removed with diffi- 
culty. Meanwhile the absorption of toxic material goes on, producing 
general swelling of the glands of the neck, a temperature that, unless 
some complication supervenes, rarely rises above 103° F., and a rapid 
pulse- rate^ to which the most careful attention should be paid. The pulse 
is perhaps the best index of the extent to which the system has become 
poisoned. It is regularly rapid in the disease, and an irregularity, espe- 
cially associated with a slowness of action, is of most unfavorable import. 



DIPHTHERIA. 681 

In about one-third of the cases there is renal disease, as shown by the 
presence of albumin, with hyaline and epithelial casts, and the urea and 
urates are increased by the fever. As the kidneys seem to be very sus- 
ceptible to the effect of the poison, these symptoms appear early, as soon 
as the third or fourth day. The quantitj^ of urine excreted at this stage 
is rarely diminished and may be increased, but hemorrhage is rare. The 
foregoing indicate intense congestion of the kidney. If actual nephritis 
occur, the urine becomes scanty, while hyaline and granular casts are 
found. Eed blood-cells make their appearance, and the patient suffers 
from oedema, together with the usual ursemic manifestations. A rather 
curious fact is recorded by various observers, — namely, that in uremic 
poisoning in diphtheria the mental faculties retain their clearness, even 
in Mai cases, to the end of life. Vomiting may occur, together with 
great nervous excitement, but at other times the ]3atient will lie in a state 
of semi- coma. 

The foregoing, excepting the uraemia, are the ordinary features of a 
straightforward pharyngeal case. The turning of the tide seems to come 
at about the end of a week, when in favorable cases the membrane begins 
to loosen and is expectorated ; the mine clears, fever subsides, heart- 
action becomes more natural, and convalescence is fairly established. 
Soreness in the throat is apt to remain for several days after the mucosa 
becomes clean, and, as is now known beyond a doubt, the bacilli remain 
for weeks, during which period the patient is a source of possible con- 
tagion to others. Even after the mild cases have run their course there 
are various sequelae which may i)rolong the disease for an indefinite time. 
In the unfavorable cases the fever remains high, the pulse becomes pro- 
gressively rapid and feeble, the skin cyanosed, moist, and clammy, and 
the mind blunted, the degree of all these symptoms varying according 
to the extent of sepsis. 

Xasnl Diplitheria. — This has always been considered one of the most 
fatal forms of the disease, but researches of recent years have led to a 
modification of the views in this respect. In some of the cases in which 
cultures reveal the Lof&er bacilli the constitutional and local symx)toms 
are mild and the patient not very ill, recovering without any special 
difficulty. There occur cases of membranous exudation in the nose due 
to other micro-organisms, the disease being called membranous rhinitis. 

Laryngeal Diphtheria. — Many cases begin in the larynx, and the most 
careful inspection will reveal no membrane in the throat. The bacilli 
are there, however, as will be shown by a culture test. These are the 
cases formerly known as membranous croup, — a name which is likelj' 
soon to pass from medical nomenclature. In these cases the pharynx is 
red, injected, and dry in contrast with the more oedematous condition 
common to many of the acute pharjmgeal inflammations. The early 
occurrence of dyspnoea at once draws attention to the larynx, and unless 
relieved by treatment the symptoms become steadily worse, breathing 



682 DISEASES OF THE LARYNX. 

is stridulons, cyanosis develops, witli a rapid and feeble pulse, and the 
patient dies of carbonsemia. In some cases a rash develops very much 
like that of scarlatina. It may come out on the second or third day, but 
more commonly does not appear until the second week. If the patient 
have been exposed to the i^oison of scarlatina, some doubt may exist as to 
exact diagnosis. There is no reason to doubt that the two diseases may 
coexist, but it is also true that a rash may be present in diphtheria 
alone. 

Lacunar Diphtheria. — Koplik^ has called attention to a class of cases 
in which the clinical features of the disease are not typical, membrane 
rarely present, and the diagnosis between diphtheria and simple angina 
extremely difficult and to the naked eye practically impossible ,• yet cul- 
tures have promptly shown the presence of the Loffler bacillus. These 
cases are, however, capable of infecting fresh throats, and of producing 
in them diphtheria with characteristic false membrane. So also cases 
resembling in microscopical appearances ordinary lacunar tODsillitis have 
been shown to be true diphtheria. These facts emphasize the double 
importance of bacteriological diagnosis and of isolation of all cases of 
sore throat, no matter how simple in appearance. 

Complications and Sequel w. — As has been said, any mucous membrane 
may be the seat of diphtheritic deposit, with corresponding symptoms ; 
but the process rarely extends forward from the fauces to the anterior 
oral cavity, and deposits in the digestive tract are also unusual. The 
respiratory system is more frequently invaded, and the deposit may ex- 
tend to the ramifications of the smallest air-tubes, presenting one of the 
most fatal types of the disease, for no mechanical relief is possible. Or, 
again, the lungs may not be invaded by the deposit, but may be the seat 
of a pneumonia. The lesions of the kidneys have already been spoken 
of, and, while in favorable cases they usuallj^ disappear, the foundation 
may be laid for permanent renal changes. All these are probably due to 
local attempts at elimination of the poison. ^N'ext in frequency to the 
kidney lesions are those in the nervous system, from which nearly all 
patients suffer to some extent. The most common manifestation is paral- 
ysis, which comes on in from three to four weeks after the cessation 
of acute symptoms, and most frequently attacks the soft palate, less 
frequently the muscles of the x>harynx, and still less often those of 
the larynx. It may succeed those cases in which the symptoms have 
not been severe, the first evidence being impairment of the voice and 
regurgitation of fluids through the nose. The upper and lower ex- 
tremities may also share in the paralysis, and least frequently of all 
the muscles of the eye. The danger of entrance of food into the larynx 
from the imi)airment of those muscles which preside over the initiatory 
stages of deglutition is at once obvious. It may be that semi-solids are 

1 New York Medical Journal, August 27, 1892, p. 225. 



DIPHTHERIA. 683 

better coutrolled by the throat than fluids, which are extremely liable 
to run down into the larynx. Fortunately, dii)htheritic parah ses, how- 
ever severe, are generally recovered from, though persistent treatment is 
often necessary to bring about this result. 

The paralyses of the extremities of trunk muscles are frequently iDre- 
ceded by disturbances of sensation, hypersesthesia, or anaesthesia. Any 
or all of these may have a very contracted localization or irregular dis- 
tribution. When the external muscles of resj)iration, and x)ossibly the 
diai)hragm, are alike involved, there are dyspnoea, short, dry cough, and 
labored, irregular breathing, and in such a case death may occur suddenly. 
Examination of the nerves and muscles in fatal cases has shown all de- 
grees of parenchymatous degeneration, hyperaemia, and hemorrhages of 
both perii^heral and central nervous organs. All these changes are the 
direct effect of the toxin of the disease upon the various structures. 

The muscle whose involvement causes the most anxiety is the heart. 
Cases often die from heart- failure after they have apparently weathered 
the storm of the acute period. This heart-failure may be due to the 
direct toxic action of the disease-poison on the heart muscles, or to the 
formation of fibrin clots in the heart itself or in some of the great vessels. 
It may come on suddenly from the eftect of some incautious movement 
in bed, or may be x^i'^ceded by a weak and irregular j^ulse. Stenosis of 
the ui^per air-passages tends of itself to weaken and dilate the heart. 
Purulent inflammation of the middle ear is not uncommon. 

Diagnosis. — The opinion has already been expressed in this chai^ter 
that in the light of present knowledge a bacteriological diagnosis alone 
can determine the existence of diphtheria, but there are many cases in 
which careful inspection and a proper analysis of the features of each 
case will make the diagnosis reasonably' sure. It must not be forgotten 
that dii)htheria was diagnosticated before bacteriology was thought of, 
nor must too much of the burden of decision in each case be thrown on 
the bacteriologist, for physicians have to act quickly and cannot wait for 
his findings. The mere presence of the Lofiier bacilli in the mouth does 
not constitute diphtheria ; there is also imi)lied the existence of a group 
of constitutional symptoms indicative of toxic effects, and the local exist- 
ence (most commonly in the throat, above or below) of a condition 
caused by the bacilli. Generally this condition takes the form of a 
fibrinous dex)Osit, but, as has been seen, it is in rare instances wanting, 
or it jnaj assume various unusual forms. Moreover, bearing in mind 
the minute details required in testing, culture-making, etc., it is evident 
that one negative result is not conclusive. 

"When called to a case, careful inquiry should be made as to the 
duration of symptoms, and any possible exposure to a disease in which 
sore throat has been a feature. If the patient be a child, say under 
seven or eight years, a suspicious case is far more likely to be diphtheria 
than if it occur in an adult. The patient should be carefully exam- 



684 DISEASES OF THE LARYNX. 

ined and the temperature taken. A sore throat which has begun with a 
high temperature is less liable to be diphtheritic than one in which the 
temperature has graduall}^ risen. A similar remark may be made with 
reference to all local throat symptoms, as pain, odynphagia, etc. In 
diphtheria they are regularly of slower development than in manj^ of the 
simple throat cases. The neck should also be searched for enlarged 
glands. The patient should then open the mouth, the tongue being 
pressed with a spoon, the latter to be put in boiling water immediately 
after using. In the j)resent day the old-fashioned plan of carrying around 
a tongue-depressor in the pocket needs to be mentioned only to be con- 
demned. A piece of wood splinting makes an excellent depressor, and 
can at once be destroyed. Observation should take in the buccal cavity, 
palate, faucial pillars, tonsillar surfaces, pharyngeal wall, and, if practi- 
cable, the mirror should be used to get a view of the nasopharynx and 
larynx. If a membranous deposit be seen, which on attempted removal 
comes away with difficulty and leaves a bleeding surface, it is due to 
some micro-organism, but whether that be the Loffler bacillus or not 
must be decided by culture test. In diphtheria the deposit is more 
likely to be on the uvula, edge of the soft palate or faucial i)illars, or 
any sharp edge or projecting point rather than on a relatively smooth 
surface like that of the tonsil. If, in the absence of membrane, there 
be, in addition to the foregoing general symptoms, evidences of laryngeal 
involvement, and the physician be able to rule out an ordinary catarrhal 
croup, the presumption is strongly in favor of diphtheria. Finally, the 
rule may be laid down that in doubtful cases the patient must be iso- 
lated and treatment instituted as if the diagnosis of diphtheria had 
positively been made. 

Differential Diagnosis. — Some of the points of contrast between diph- 
theria and other maladies with which it may be confounded have 
already been mentioned. It remains to be added that in scarlatina the 
exudation is generally confined to the tonsils, or at least does not, 
except in rare instances, appear on the fauces. Sometimes an ap- 
parent false membrane in this and other throat conditions is only 
tenacious mucus which has become spread evenly over the mucosa, but 
can easily be brushed off with a firmly wound cotton carrier and leave 
no bleeding surface. Naturally the appearance of the scarlatinal rash 
will decide the diagnosis, but it must be remembered that there are cases 
of scarlatina in which the rash is inconstant or even entirely wanting, 
except perhaps over very small areas and for a very short time, and it is 
in the earlier stages that differential diagnosis is so difficult. Subsequent 
paralysis may confirm suspicion as to the exact nature of a case which 
during its clinical course has been doubtful. 

In measles there is rarely any false membrane, and the symptoms of 
the accompanying coryza, with the appearance on the fourth or fifth day 
of the catarrh and of the characteristic rash, or the earlier appearance 



DIPHTHERIA. bOO 

of the peculiar buccal eruption (p. 695), make the diagnosis easy. The 
tendency of measles to involve the entire air-tract, and its characteristic 
cough, are also of service in helping to a decision. 

The so-called acute glandular fever of children presents some of the 
constitutional and some of the local external symptoms of diphtheria, 
but inspection of the fauces shows no exudation. Students occasionally 
mistake the deposits of leptothrix mycosis for diphtheria, but there are 
here no constitutional symptoms, and examination of the deposits with 
the probe will at once reveal their true nature. 

The differential diagnosis from the various forms of tonsillitis has 
been sufficiently dwelt on. Xon- diphtheritic deposit is less apt to 
become necrotic and give off a fetid discharge. 

True and False Diphtheria. — The systematic and extensive culture 
examinations of the last few years have shown that there are bacilli 
identical in appearance with the Loffler bacilli and yet harmless, as they 
seem incapable under their usual conditions of producing toxin. There 
is still another organism having a habitat similar to that of, and resem- 
bling, the Loffler bacillus in some respects, but differing in others. Park 
notes that it is rather short, plump, and more uniform in many par- 
ticulars than the true dii)htheria bacillus. They are found in varying 
abundance in about one per cent, of normal nose and throat secretions ; 
apparently they have no connection with true diphtheria, and their 
exact source is unknown. To them the name ' ' pseudo-diphtheria bacilli' ' 
has been given. The term false diphtheria is anatomical rather than 
otherwise distinctive, and refers to the exudations found under various 
conditions. 

Mixed Infection. — As has been stated, culture tests reveal an extensive 
flora in most cases of diphtheria. The most common organisms are the 
streptococcus, staphjdococcus, and pneumococcus. It is to the presence 
of these that the various unusual clinical manifestations of diphtheria 
are largely if not wholly due. The action of antitoxin on a case of jDure 
culture diphtheria of the LoflSer bacillus can be predicated with great 
constancy, but not so if there be an association with the organisms above 
mentioned. The two former are the cause of the distinctly septic features 
of the disease, and the latter of the broncho-pneumonia so often compli- 
cating it. It seems to be true that ^- when other bacteria are associated 
with the dii^htheria bacilli they mutually assist one another in their 
attacks on the mucous membrane, the stre^Dtococcus being particularly 
active in this respect, often opening the way for the invasion of the 
deeper tissues or supplying needed conditions for the development of 
their toxins. Thus, diphtheria is not always a primary, but often a sec- 
ondary disease following some other infection, as measles or scarlet fever. 
In most fatal cases of broncho-pneumonia following laryngeal diphtheria 
there are found not only abundant pneumococci or strei)tococci in the 
inflamed lung areas, but also in the blood and tissues of other organs." 



686 DISEASES OF THE LARYNX. 

As these infections are in no way influenced by the diphtheria anti- 
toxin, they frequently are the cause of the fatal termination (Park). 
Baumgartner (quoted by Shurly) insists on the essential identity of 
croupous and diphtheritic inflammations. 

Prognosis. — The mortality of the disease varies greatly, being high in 
some epidemics and low in others. The mortality-curve for a long 
series of years shows alternate rises and falls. It is said that the years 
in which antitoxin treatment has been carried out have been sj'nchronous 
with a natural depression of the curve, and that to this fact rather than 
to the curative powers of the remedy has been due the lessened mortality 
of very recent years, but time alone can prove or disprove the truth of 
this statement. The more nearly the bacteriological development in a 
given case approaches to a pure culture of diphtheria bacilli the more 
likely, of course, is it to recover ; hence the use of the antistreptococcus 
serum may become supplemental to that of the diphtheria antitoxin. 
The younger the i)atient the more unfavorable the i)rognosis, ^nd while 
both sexes are affected alike, statistics show (Jacobi) that the mortality 
is greater in boys than in girls. The outlook is better when the process 
is circumscribed and confined to areas with relatively scanty lymph 
supply. Laryngeal cases are more fatal than those in which the process 
is limited to the pharynx. But little can be i)redicted from the purely 
febrile features of a given case. Intermittence of the pulse, excessiA^e 
swelling of the glands, evidences of severe renal implication, and es- 
pecially pulmonary complications are always of the gravest import. The 
mortality varied from thirty to fifty per cent, before antitoxin was used. 
It now varies from ten to twenty per cent. 

Treatment — This may be divided into : (1) prophylaxis and (2) treat- 
ment of the disease. 

Preventive measures may concern the patient's general environ- 
ment or merely the local condition of his upper air-passages. General 
measures are comprised under the broad designation of sanitation, which 
includes the proper maintenance of water and sewage systems, free ven- 
tilation, disposal of house refuse of every kind, the establishment of a 
strict quarantine during the existence of a case of the disease, and the 
thorough disinfection of all articles which have been used about the sick- 
room. Municipal authorities in all our large cities require cessation of 
school attendance of well children in the family of the patient, nor are 
they readmitted until the teacher receives notification from the Board 
of Health that they may be allowed to come back. This notification is 
not given until a culture from the patient's mouth is free from bacilli 
and the premises have been disinfected. Until these are accomplished 
the authorities look on the case as a source of possible contagion. Under 
the heading of quarantine, the duties of the physician in regard to personal 
disinfection, change of clothing, cleansing of hair and beard, etc., must 
never be forgotten. For mouth-washes to be used by the well members 



PLATE XIV. 



-^^ 



fi>K% 



«:/A '^ 
















■*-.^ 



^^ 









Diphtheria bacilli, showing irregular form, but Characteristic diphtheria bacilli, showing very 
unusually even staining. Many xerosis bacilli have long and irregular forms, 

a similar appearance. 



i' - r 


tP !>■' 


^ ' 


' * , ^ 




^3 


I / 







,'0 fS^ 

/ 


4 




■. 1 1 




C"' 


V 


^. 












^ 

^ 



}'st'U(iiHliphthci-ia bacilli with a ivw di])loc()C( 



t'seudodiphthuria bacilli with a few diplococci. 












ji ..f\ 






.,£_ii 



*;^ -* -t J 



Streptococci and diplococci from a culture growth 
on blood-serum from a case of pseudodiphtheria. 



Streptococci and diplococci as seen in a smear 
made directly from the exudate in a case of pseu- 
dodiphtheria. 



DIPHTHERIA. 687 

of a household in which the disease exists many antiseptic remedies 
have been suggested, but any one, thoroughly used, is doubtless good. 
Perhaps for a gargle resorcin in a five per cent, solution is the best. 
For use in the nose and nasopharynx with the coarse atomizer, douche- 
cup, or syringe, preparations of the listerine type, one teaspoonful to a 
glassful of lukewarm water, are to be recommended. 

During the intervals between epidemics, or as soon as circumstances 
render it prudent, an endeavor should be made to i^lace the upper air- 
tract of children in a normal condition. Enlarged tonsils should be 
excised, catarrhal states remedied, and all conditions which favor the 
development of contagion removed. When once the disease is fairly 
established the question of throat disinfection immediatelj' arises, and 
nearh' every antiseptic in vogue has been suggested. Perhaps hydrogen 
dioxide diluted with twice its volume of lime-water is as useful as any, 
and it should be followed by a solution of mercuric bichloride (1 to 
4000). In young children there may be substituted for the bichloride a 
listerine solution, a teaspoonful to four ounces of water, and such ai^pli- 
cation may be made every two hours. 

The mode of applying these remedies must be determined by circum- 
stances. If the patient be old enough to gargle, they may be so used, 
but the condition of the heart often renders it extremelj^ dangerous to 
make the exertion necessary for gargling. Therefore the physician 
should resort to sprays or irrigation of the mouth, the patient lying on 
his side at the edge of the bed. For very young children probably the 
spray is the most practicable means. In regard to subsequent local 
applications, it maj^ be said that they are permissible only when the 
patient is old enough to co-oi^erate with the physician ; to thrust the 
applicator in at random and swab it over the throat will do more harm 
than good. For topical use there may be employed the Loffler solution 
(p. 694), bichloride solution (1 to 500), pure lactic acid carefullj^ limited 
to the deposits of membrane, perchloride of iron, strong silver nitrate 
(from forty to sixty grains to the ounce), a solution of zinc chloride 
(U. S. P.), menthol in a bland oil, half a drachm to the ounce, etc. Steam 
inhalations may be used, as in spasmodic croup, but thej^ must not be 
continuous for fear of their dex^ressing effects. The air of the sick-room 
may be impregnated with an antiseptic A^apor, and of the many proposed 
none is more efficacious than the one so long employed by the late J. 
Lewis Smith, — viz., oil of eucalyptus and carbolic acid, of each, one 
ounce, and oil of turpentine, eight ounces ; two tablespoonfuls of this 
mixture should be placed in a quart of water, which should be allowed 
to simmer near the patient, the containing vessel, such as an ordinary 
basin, having a broad surface so that the contents shall not take fire. In 
nasal cases the nose should be sprayed, but strong solutions here are 
hardly practicable, and the latter remark applies also to the larynx. 
With older children sprays can be used, but in any case the inspired 



688 DISEASES OF THE LARYNX. 

air may be medicated, and with a little car6 all benefits possible witli 
this method can be obtained. The nasopharynx should be sprayed, and 
the various solutions, especially the Loffler toluol combination, be used 
on an applicator ; but once again the caution is given that, unless the 
patient be fairly tractable, such measures are apt to do more harm than 
good. An ice-water coil over the neck is often grateful. 

Dii)htheria is now regarded as a local malady leading to systemic in- 
fection. The object of all the foregoing measures is to destroy the germ 
growth at the site of inoculation and thus prevent toxin formation. 
With the same end in view various solvents of false membrane have been 
tried at different times, such as trypsin or papain, a proteolytic ferment 
obtained from papaw milk (the juice of the carica papaya, a tree of South 
America), which will dissolve fibrin in a menstruum of any chemical 
reaction. The introduction of antitoxin has led to a general abandon- 
ment of these remedies. 

Constitutional treatment should be commenced as soon as the case is 
seen. Those who believe in antitoxin therapy will, perhaps, not be par- 
ticularly interested in other i)lans, but this remedy may not be available, 
and it is well in such a juncture to have a definite plan of procedure. 

At the start the bowels should be moved by calomel, one-tenth of a 
grain being given every half-hour up to full and free catharsis. A bed- 
pan must be used and the patient kept recumbent, and from the very 
start care taken to save him every kind of exertion. The most popular 
remedy is muriated tincture of iron in glycerin j of this a child of five 
years may take ten minims every three hours during the acute stage. It 
undoubtedly strengthens the vital powers against the onset of the mal- 
ady. There is no reason to believe that the time-honored combination 
with potassium chlorate is of any more benefit than the iron alone, and, 
moreover, the latter remedy is not devoid of danger, in young children 
at least. The mercurials may be given in small and continuous dosage, 
say one-one-hundredth of a grain of the bichloride every two or three 
hours. Small tonic doses of quinine and alcoholic stimulants to keep 
up the action of tiie heart, sup]3lemented by digitalis, strophanthus, and 
especially strychnine, will all find their appropriate place. Calomel 
may be given by sublimation, especially in the laryngeal cases. From 
five to ten grains of the drug are placed in a pan over a protected spirit- 
lam]3, and the whole placed under a crib covered by a tent. The quantity 
is renewed two or three times at intervals of from a half to three-quarters 
of an hour, the effect being cai^efully watched, so as to avoid salivation. 
If there be much mucus in the air-passages, one or two doses of atropine 
may be of service. 

The constitutional remedy most in vogue at the present time is anti- 
toxin, and the physician should employ the concentrated preparations, — 
that is, those of high antitoxin-unit strength per cubic centimetre. No 
preparation is reliable after an age of six months. 



DIPHTHERIA. 



689 



Immunization. — It is possible to employ antitoxin in immunizing those 
exposed to the disease. For this purpose an injection of from three 
hundred to six hundred units will prevent an attack for a period of 
two weeks. The injection must then, in case of continued exposure, be 
repeated. When the disease has fairly started a curative effect is still 
possible by preventing the continued action of the toxic principle. It is 
at once apparent that no effect is possible on tissues already damaged. 
Antitoxin is rather preventive of further bad results, and consequenth^ 
should be used at the earliest possible moment. It seems to act not by 
a chemical neutralization of the dii)htheria toxin, but by a re-enforce- 
ment of the natural resisting power of the patient, notably through the 
medium of the blood-plasma. 

A good form of syringe for injection is the one shown in Fig. 275. 
The most scruj)ulous antisepsis should be observed, and care taken to 

Fig. 275. 




Ermold's antitoxin syringe. 



exclude all air-bubbles from the barrel when it is filled. The injection 
should be made ver}^ slowly in the loose skin between the shoulder-blades 
or on the abdomen. The site should first be carefully washed with soap 
and water and then with an antiseptic solution. From one thousand to 
two thousand units should be employed, according to age and severity 
of symptoms, and the injection may be repeated in twelve hours. It is 
rarely necessary to exceed a total of six thousand units. As the fluid is 
quickly dispersed in the tissues, it is advisable not to rub the skin ele- 
vated by the injection, but to place a protective over the puncture for 
a short time. Pain at this site may be relieved by a hot- water bag or a 
cloth dipped in a warm saline solution. The possibly bad effects which 
follow injections can generally be ascribed to impure preparation or some 
fault in method. The urticarias which were so common, as were the 
joint troubles, after the injections of earlier days are now rarely seen. 
There is some reason to believe that thej^ were due to the large quan- 

44 



690 



DISEASES OF THE LARYNX. 



titles of horse-serum used and not to the antitoxin elements. The good 
effects are often marvellous in their promptness, the membrane soon 
beginning to show a line of demarcation and curling up at the edges ; 
the temperature falls, the pulse becomes slower and of better quality, and 
symptoms of depression vanish ; in fact, the improvement is so rapid 
that it is often difficult to keep the patient quiet and in bed as long as 
judgment dictates. 

In cases of laryngeal diphtheria in which, in spite of the antitoxin, 
the symptoms of laryngeal obstruction become increasingly urgent and 
the child cyanotic, with a small and infrequent pulse, the alternatives 
are presented of tracheotomy and intubation. The former has from the 

Fig. 276. 




O'Dwyer intubation set. 



earliest ages of surgery been a well-recognized means ; the latter had 
been attemjpted by various workers in former years, but it remained for 
O'Dwyer, of New York, to make it a practical matter, and so careful 
was his study of the question and his appreciation of all the pathological 
and mechanical problems involved that very little of essential value has 
been added to his original communications on the subject. 

Herewith are figured the various instruments required in the opera- 
tion. The child should be wrapped in a blanket, only the head being ex- 
posed, and firmly held by an assistant, who places the patient's legs 
between his own, the child's back being tightly held against the assistant's 
chest. Another assistant holds the head firmly in the median line. If 



DIPHTHERIA. 691 

the patient be lying in bed, absolute quiet on bis part must be maintained. 
The gag is placed between the molar teeth, and the operator then hooks 
forward the epiglottis with the left index-finger. The introducer, with 
the tube attached and threaded with braided silk, is then passed into the 
mouth, its handle being held at first well down on the patient's chest 
and the thread wound about the surgeon's little finger. As soon as 
the end of the tube is over the larynx the handle of the introducer is 
abrui)tly turned so as to render the tube vertical. The latter is now 
passed down into the larynx, the introducer (also called obturator) dis- 
engaged by forward pressure on the handle and removed, and the tube 
pressed down into position by the left index-finger. The thread is passed 
over the left ear of the i^atient and the gag removed. If the tube be 
properly inserted the patient coughs, giving a peculiar sound not easy 
to describe, but when once heard easily recognized again. The color of 
the child improves, breathing becomes easier, and it often at once falls 
asleep. If the tube be passed into the oesophagus, there is no relief to 
the dyspnoea, no peculiar cough, and the tube will begin to go farther 
down, as evidenced by the gradual disappearance of the thread, which 
can be used to remove it. If satisfied that the tube is in proper posi- 
tion, the oi3erator reinserts the gag, places the left index-finger on the 
tube to hold it in position, and withdraws the thread, the loop having 
been cut. Cautions necessary are to keep in the median line, to be gen- 
tle in manipulation, to keep the back of the finger in contact with the 
posterior wall of the i^harynx, forming, as it were, a continuation of it, 
and to make the sudden turn of the obturator so as to bring the tube 
into the vertical position. In removal of the tube the gag is introduced 
as before, the left index-finger x^laced on the tip of the tube, care being 
taken not to make i^ressure, the extractor introduced, and its jaws o^^eued 
so as to engage the tube, the movement of extraction being the reverse 
of that of introduction. 

If the tube happen to be swallowed, it will probably i3ass through the 
bowels without difficulty. If it be coughed out in a few hours, it must be 
reinserted if demanded by the symptoms. It is a good plan to remove it 
on the fourth or fifth day, even if immediate reinsertion be required. 

The advantages of intubation over tracheotomy in diphtheria are : 
absence of a wound, freedom from shock, and the fact that air through 
the natural channels in the former method, even in dii^htheria, is less 
liable to excite pneumonia than is air through a tracheotomy tube. In 
adults it seems that in diphtheria clinical results are better from trache- 
otomy than from intubation. But in general it maj^ be said that the 
latter operation is gradually supplanting the former under the conditions 
named. 

The diet in diphtheria should consist of liquid foods, such as milk, 
beef extracts, yolks of eggs, broths, etc. , and should be given at intervals 
of from two to three hours. Orange juice is both grateful and permis- 



692 DISEASES OF THE LARYNX. 

sible, and ice-cream^ if made from good materials, may be taken in small 
quantities. As soon as the membrane lias cleared off sufficiently to 
allow semi-solid foods, jellies and custards, with soft animal foods and 
the cereals, may be added. The condition of the urine will to some extent 
determine the time of resumption of full diet. 

The intubated child is obviously restricted to fluid food, which may 
be sucked up through a tube from a vessel lower than the level of the 
head, or the patient may lie on the back with the head lowered so that 
the pharynx is lower than the larynx (Casselberry position). Other 
methods are rectal enemata and nasal feeding, the latter being easily 
carried out with a catheter attached to a glass funnel by means of tubing. 
This method has the very great advantage of enabling the quantity of 
nourishment entering the stomach to be accurately determined. 

The various complications are to be treated according to general 
therapeutic principles. In the cases of i:)aralysis, strychnin^ must be 
pushed to full physiological effect and electricity carefully and system- 
atically employed. Palatal paralysis may require nasal feeding, as above 
suggested. 



CHAPTEE XX. 

THE PHARYXX AND LARYNX IN THE EXANTHEMATA AND OTHER 

FEVERS. 

In many of the exanthemata and other febrile conditions inflammation 
of the mucosa of the pharynx and larynx occurs so constantl}', and at 
times assumes such severity, that it demands separate consideration. The 
most common affections in which this complication occurs are scarlatina, 
measles, rotheln, variola, varicella, typhoid and typhus fevers, malaria, 
and influenza. 

Scarlatina. — In this disease the inflammation of the pharynx and lar- 
ynx is most constant. Manj' x^^rsons who seem immune to the disease 
itself suffer from a sore throat when brought into contact with the scarla- 
tinal poison. It is possible that such throats represent an abortive form 
of the fever. The throat symptoms regularly precede the appearance of 
the rash. The initial appearance differs in no way from that of an 
ordinary catarrh, but by the time the case comes under observation this 
stage has generally been succeeded by one of redness with swelling of 
the tonsils ; more severe grades of infection show a diffused, brawny 
swelling of the parts, with perhaps a lacunar tonsillitis, or more commonly 
a distinct membranous exudation with enlargement of the submaxillary 
glands and even an induration of the entire cervical region. This initial 
invasion is due usually to streptococci, though staphylococci and ba- 
cilli coli communis have been found, and occurs, as a rule, before the end 
of the first week. In the second or third week there may be a compli- 
cating diphtheria with Loffler bacilli. The gross appearance of the mem- 
branes does not distinguish one from the other, and a bacteriological test 
should be made in order to determine the proper therapeutic measures. 
After subsidence of these affections the lymphatics are often left inflamed, 
which inflammation may lead to serious consequences. The exudate may 
extend from the visible parts of the pharynx to any of the neighbor- 
ing areas ; later comes a clearing off with attendant ulcers, which soon 
heal, or gangrenous changes may occur. These severe forms of scar- 
latinal affection were formerly called '^scarlatina anginosa," and in 
such the throat symptoms are apt to overshadow all others. Occa- 
sionally there are a purulent infiltration into the deeper parts and vari- 
ous manifestations of sepsis, an occasional sequel being retropharyngeal 
abscess. 

Similar changes affect the larynx, though less constantly, as evidenced 
by the fact that cough and hoarseness are not regular features of the 
disease. Generallj' the inflammation here is of a catarrhal nature, 

693 



694 DISEASES OF THE LARYNX. 

though occasionally there may be oedema, membranous deposit, gangrene, 
and abscess with accompanying symptoms of laryngeal stenosis. Lennox 
Browne calls attention to the fact that in the renal complications of 
scarlatina there may be a condition of acute laryngeal oedema lasting 
weeks, or even months, after the subsidence' of the fever proper. 

Treatment. — The treatment of the throat complications of scarlatina 
is of the greatest imiiortance, not alone as promotive of the patient's 
immediate recovery, but also as tending to the prevention of disastrous 
sequelae which, while not necessarily dangerous to life, threaten bodily 
integrity in most important directions. The end sought is the pre- 
vention of secondary infection from the results of throat diseases. As 
soon as the existence of a sore throat is discovered, even before there is 
any definite diagnosis of scarlatina possible, a systematic disinfection of 
the pharynx should be commenced. At the same time the severity of the 
infl.ammation may be lessened by the application of cold to the neck, 
preferably by the Leiter coil ; but if this be not at hand, ice-bags or even 
ice-cloths may be used. The choice of an antiseptic for throat cleansing 
is of minor importance, so long as the one selected is used thoroughly and 
systematically : it may be utilized as a gargle, in spray or douche, or may 
be applied topically. For very young children the spray is undoubtedly 
the best method, but an atomizer throwing a coarse spray should be used. 
For older children the gargle or the douche may be employed. The latter 
is very useful when the inflammation has involved the postnasal space 
or nose. When only the pharynx is involved, the child should lie on its 
side at the edge of the bed and a stream allowed to run in and out of 
the mouth under very low pressure, effected by having the level of the 
supply-bag but slightly higher than that of the bed. In case the inflam- 
mation involves the nose and nasopharynx, the nozzle may be placed in 
one nostril, the mouth being held open so that the stream will emerge 
from the other, i^asal douching is not free from objections, but if per- 
formed with the i)recaution noted, it is a most thorough method of 
cleansing. The child should, if possible, avoid swallowing, and if gently 
managed, will submit to the manipulation without trouble. In the man- 
ner outlined solutions of boric acid may be used, a drachm to the pint, 
salicylic acid in the same strength, or the listerine type of preparations 
in the strength of a teaspoonful to four ounces. In the atomizer equal 
parts of hydrogen dioxide may be employed, followed by some distinctly 
alkaline solution, such as Dobell's. Unless the general condition con- 
traindicates, this should be done every two hours. With still older 
children, who can control the throat sufficiently well to allow topical 
applications, the dioxide may be used in full strength (the forms sold 
commercially as ''pyrozone" have given the writer satisfaction), or the 
well-known Loffler iron-toluol solution, the formula of which is as fol- 
lows : toluol, thirty -six parts ; absolute alcohol, sixty parts 5 solution of 
the sesquichlorate of iron (old German Pharmacopoeia), four parts ; for 



PHARYNX AXD T.ARYXX IX EXANTHEMATA AND OTHER FEVERS. 695 

the latter may be substituted the TJ. S. P. liquor ferri chloridi. Thorough 
cleansing with an antiseptic solution and drying as far as possible by 
means of cotton pledgets should x^recede the topical applications. 

All the foregoing, and especially the hydrogen dioxide, should be 
used with care. A distinct caution is given against the frecxuent appli- 
cation of too irritating solutions. More harm than good is thereby done, 
for areas may be denuded of their epithelium and further infection thus 
encouraged. If examinations of the membranous de^^osit reveal the 
Loffler bacillus, the physician should proceed at once as in diphtheria. 
In some cases of severe streptococcus infection the antistreptococcus 
serum has yielded good results. 

Measles. — In measles the clinician may find a diffuse redness or a 
punctate blotchy eruption in the pharynx, with maximum distinctness 
on the soft palate, possibh' on the tonsils or posterior faucial pillars. In 
some cases it antedates the skin eruption, some authorities going so far as 
to say that three days may elapse between the palatal and skin manifes- 
tations. There is constantly found a catarrhal condition involving the 
entire upper air-tract from the nose down to the trachea and larger 
bronchi, giving its characteristic symptoms, with the peculiar ^'iron" 
cough. These catarrhal symptoms usualh^ last four or five days and 
are of an obstinate type, gradually lessening as the exanthema appears 
on the skin and subsiding with the disappearance of the eruption. 

Mention may here be made of the so-called Koplik's sign, which, accord- 
ing to this authority, appears on the buccal mucous membrane from one to 
five days before the skin outbreak. The eruption is in the form of small, 
irregular, bright reddish spots, in the centre of which is a bluish-white 
speck. Ordinary manipulation does not remove them ; they persist until 
the cutaneous rash is at its height, when they begin to disappear. Strong 
direct daylight is necessary for their detection, but it is held that this 
condition is absolutely pathognomonic of measles. All other spots on 
the throat in general are non-significant until suspicions are confirmed 
by the appearance of the skin lesion. 

In the larynx catarrhal changes are, as has been indicated, nearly 
always present. They usually subside as the rash fades, and are, as a 
rule, not dangerous, though there occur at times spasmodic attacks with 
some signs of local obstruction, and intubation has been necessary. Ul- 
cerative changes are uncommon, but have been observed, and in such 
cases the laryngeal symptoms become progressively worse, and death may 
result f]^om cedema of the glottis. Membranous laryngitis in measles 
may be truly diphtheritic or due only to streptococci and other pyogenic 
organisms. This condition is not seen in private practice, but has 
caused terrible mortality in public institutions. The diagnosis may be 
difiicult unless there be membrane in the pharynx. Before the true con- 
dition is appreciated broncho-pneumonia may have set in, and doubtless 
the membrane has already invaded the trachea and bronchi : hence the 



696 DISEASES OF THE EARYXX. 

surgeon has no means at liis command to ward off the inevitable end. 
Gangrenous changes are possible, and glandular involvement will depend 
on the severity of the local lesions. For all the foregoing there is no 
special treatment. Systematic cleansing of the upper passages renders 
the lower much less liable to infection. 

Eothehi {German Measles). — Some authorities find sore throats in not 
more than one-fifth of all the cases of German measles, while others be- 
lieve that they are constantly present. There are no special appearances 
which are distinctly characteristic of the disease. A non- distinctive 
exanthema may appear on the palate for a few hours only. The tonsils 
swell usually in correspondence with the severity of the disease, which, 
as seen in the United States at least, is generally mild. Dysphagia is 
often quite sharply felt, and is rather out of i:)roportion to the local 
appearance of the throat. An occurrence universally admitted as of 
general importance is the enlargement of the lymphatic glands at the 
angle of the jaw. Eeed has reported a case in which the eruption ap- 
peared on the palate and tonsils alone, the skin being free. No special 
treatment is called for. 

Variola. — The throat symptoms in variola may commence during the 
stage of incubation or that of invasion. The exanthema seems to repro- 
duce itself in the mucous membranes, though modified by the structure 
of the latter. There may be simply a dusky injection of the parts, or 
the usual appearance of a catarrhal inflammation, which causes great 
irritation and is a feature of which the patients bitterly complain. In 
hemorrhagic small-pox there may be ecchymotic spots on the pharyngeal 
mucosa with the customary involvement of the lymphatics. In ordinary 
cases the typical eruption appears on the palate, tonsils, and often in the 
larynx and trachea, going through the regular papular, vesicular, and 
pustular stages, modified by the moisture and attrition of the surfaces on 
which it appears. In severe cases the localized deposits on the pharyn- 
geal mucosa may be followed by a general tendency to suppurative 
processes. The secretion is thick and tenacious and is expectorated by 
the patient with great difficulty. 

In the larynx the changes are more severe, and there may be either 
catarrhal, ulcerative, or membranous conditions. The laryngeal symp- 
toms are apt to appear towards the close of the first week of the disease, 
and are of the customary variety, except that the cough appears unusually 
harsh and dry, and there may be severe and even dangerous dyspnoea. 
A whispering voice at this stage is regarded as a very bad sign. Nat- 
urally the development of a rash, such as that of variola, near the larynx 
may be followed by oedema of the organ. Ulceration with destruction and 
erosion of the various cartilages — even gangrene — may also be present. In 
a bacteriological sense true diphtheritic deposit is extremely rare. Browne 
reports the occasional fixation of one vocal cord from ankylosis of the crico- 
arytenoid joint, but denies the existence of any true muscular paralysis. 



PHARYXX AND LARYNX IN EXANTHEMATA AND OTHER FEVERS. 697 

It is in the confluent and malignant types of variola that these more 
severe complications are to be expected, for in the milder cases not much 
trouble is experienced. Treatment consists of local antisei)sis and seda- 
tives, with such mechanical attention to the larynx as it may call for. 
Gargles of a weak solution of potassium chlorate or of some salt, as borax 
or baking soda, are grateful to the patient, and may be followed by the 
application of cocaine (caution with children) or menthol in glycerin 
(Kj'le). The patient may be allowed free use of ice-i)ellets and bland 
and demulcent drinks, such as elm, flaxseed, acacia, etc. In case the 
patient is not able to gargle or rinse the mouth freely, a soft swab 
dipi^ed in a solution of borax should be used several times a day. and a 
most vigorous attempt made to keep the upper passages well disinfected. 
The food should be bland and unirritating, soft jellies and iced milk 
offering the best dietary. Externally, ice-bags or the Leiter coil may be 
applied, for while they may not materially reduce the severitj^ of the 
local inflammatory changes, they will greatly relieve the pain. 

VarlceUa. — The physician should expect to find a rash on the pharynx 
and surrounding parts in varicella. Bj' the time the case comes under 
observation there will be vesicles, which, owing to the attrition to which 
they are subjected, quicklj^ break down, leaving aphthous ulcers sur- 
rounded by a well-marked i-eddish zone. They are most marked on the 
palate, the larynx rarely being involved, and when it is the case ends 
fatally. Treatment is along the lines previously indicated. 

Typhoid Fever. — A certain degree of pharyngitis is almost always 
present in typhoid fever. It may assume a lacunar, follicular, ulcer- 
ative, or membranous, but rarely a diphtheritic type. Aphthous con- 
ditions of the buccal mucosa are always present. Swallowing is more 
or less difficult from the beginning, owing to the dryness of the throat, 
and later there seems to result, doubtless from the continued high body 
temperature, partial paresis from granular degeneration of the muscular 
fibre. Cases in which the local lesion expends itself on the lymphoid 
structures are to be regarded as analogous to the invasion of the intestinal 
lymph-nodes. In some instances there is a characteristic symmetrical 
ulceration on the faucial pillars. It presents itself as a shallow oval 
patch, the long diameter being vertical, slightly excavated, and cov- 
ered with a greenish pellicle, which, however, is merely part of the buc- 
cal mucus, and is easily removed. The edges are sharply defined, and 
the patch may look as if punched out. Andre Schaefer,^ who care- 
fully studied nine of these cases, was not able to find the bacillus of 
Eberth on the surface, but only those micro-organisms commonly found 
in the mouth. The staphylococcus aureus was found in five out of the 
nine cases. 

The laryngeal changes in typhoid are far more common and of graver 

1 These de Paris, 1899. 



698 DISEASES OF THE LARY^sX. 

significance. They seem to be frequent, being found in about ten per 
cent, of all tj^phoids coming to autopsy. Judging from clinical reports, 
they are more common in Europe than in this country, but it is believed 
that modern antipyretic methods are lessening their frequency. It is 
now generally agreed that these laryngeal ulcerations are, so far as causa- 
tion is concerned, practically local reproductions of the changes seen in 
Peyer's patches and other abdominal lymphoid structures. They are 
probably produced by erosion of the mucosa rendered vulnerable by 
toxins, and Eichhorst has found in them the bacillus of Eberth. They 
occur relatively late in the disease. The favorite site for laryngeal 
ulcerations is the posterior surface of the organ, extending thence as 
superficial ulcerations to the posterior portion of the vocal cords and 
ventricular bands. They may be solitary or in groups, and are usually 
superficial, but may involve cartilage, leading to perichondritis and ne- 
crosis ; but most of them heal without sequelae. A further analogy to 
the intestinal lesion is seen in the fact that the sloughing period of the 
laryngeal ulcer coincides with that of the bowel. Pressure on the pos- 
terior portion of the larynx from the recumbent position is doubtless an 
Important factor in the localization of the process. Paresis of the mus- 
cular structures of the larynx may persist for some time after recovery 
from the general febrile condition. Statistics of localization and of the 
particular cartilage involved are given by Keen ^ as follows : supraglottic 
fifty, glottic eighteen, infraglottic thirty-six, cricoids forty-three, aryte- 
noids thirty-three, other cartilages seven. The epiglottis is not always 
affected, but cases have been reported in which fully one-half its sub- 
stance was lost by ulceration. 

Symptoms of all the foregoing processes take the forms of hoarseness, 
cough, dyspnoea, etc., and possibly laryngeal oedema, according to the 
severity of the case. Laryngeal stenosis may demand tracheotomy, or, 
in cases arising from perichondritis, laryngo-fissure. Under ordinary 
circumstances a proper therapy consists of sedative si)rays or inhalations. 

Typhus Fever. — The same series of lesions which characterizes typhoid 
fever is also found in typhus, but less frequently. Pharyngeal catarrh 
is the most common condition, with the usual masses of sticky mucus 
rendering swallowing difficult, but there may be membranous deposits, 
ulcerations, and even gangrene. The laryngeal lesions are of the same 
character as in typhoid, but less commonly seen. The mucous mem- 
branes are all deeply injected and of a dusky hue. 

Malarial Fevers. — Except in the most severe forms of malarial fever, 
which are rarely seen in our northern latitudes, distinctive lesions of the 
pharynx and larynx are absent. Forchheimer believes that the whole 
of the respiratory tract may suffer from malarial poison, and it is a fact 
that there are seen certain forms of tonsillitis in which quinine acts far 

^ Quoted by Thacher in Twentieth Century Medicine, vol. xvi. p. 595. 



PHARYNX AND LARYNX IN EXANTHEMATA AND OTHER FEVERS. 699 

more promptly than other remedies. Laryngeal involvement more often 
takes the form of croup, and in any obstinate case particular care should 
he taken to investigate the previous history of the patient, examine the 
spleen, and look for malarial organisms in the blood. In malarial fever 
generally the condition of the pharynx and larynx requires no special 
attention. 

Influenza. — In a general way the lesions of influenza localizing them- 
selves in the uj^i^er air-tract are of a catarrhal nature and are apt to be 
severe. The mucus which is formed in these areas is usually especially 
tenacious, and later in the attack the discharge becomes distinctly puru- 
lent. Glasgow ^ has described a form of disease of the upper air-passages 
which he calls septic oedema, and which he thinks maj" be one of the 
protean manifestations of influenza. It may affect the nares, palate, 
pharynx, or larynx. In certain cases the hypersemia of the larynx has 
been so great as to lead to actual hemorrhage ; in others the lymphoid 
oedema has been principallj' subglottic, so that on inspection the larynx 
has shown three sets of parallel folds, — the false and true cords, and 
below the latter the subglottic infiltration. Other lesions observed have 
been membranous patches looking like diphtheria, parenchymatous and 
lacunar tonsillitis, abscess formation, infiltration of the submaxillary and 
cervical tissues, as well as circumscribed glandular enlargements at these 
points, various pareses and jiaralyses, and oedema of the larynx may 
supervene. Lazarus ^ believes that there is a form of the disease in which 
the i:)rimary localization is in the muscular and submucous tissues, 
causing marked motoi^ disturbances, while on the mucosa only slight 
evidences of catarrhal lesions are visible. Changes in the larynx seem 
to be more marked in the posterior portion of the organ. 

The symptoms of all the foregoing conditions present nothing unusual, 
except that all clinicians unite in calling attention to the constitutional 
disturbance and prostration, which are out of all i)roportion to the ap- 
parent local change. Treatment is along lines suggested in foregoing 
paragraphs. Cases should be carefully watched until all the toxic ma- 
terial generated by the disease has been eliminated from the system. 

^ Trans. Amer. Laryngol. Assoc, 1889, p. 18. 

^ Quoted by Finckler in Twentieth Century Practice, vol. xv. p. 120. 



CHAPTEE XXI. 

FOREIGN BODIES IN THE PHARYNX AND LARYNX. 
FOREIGN BODIES IN THE PHARYNX AND (ESOPHAGUS. 

The list of foreign bodies whicli have been found in these passages 
includes small masses of nearly all the various materials used in ordinary 
life. The most common ones are pits of fruits, bones in foods, especially 
of fish, bits of the softer bones of fowls, pins, needles, bristles from 
tooth-brushes, coins, buttons, and tooth-plates. Xaturally the vast ma- 
jority are swallowed, but the possibility of the entrance of sharp bodies 
from the outside or from the posterior nares must not be forgotten. 

In the Pharynx. — The most frequent sites of fixation in the pharynx 
are the faucial isthmus and the tonsillar surfaces, less frequently the 
lateral wall of the pharynx, the glosso-epiglottic space, and the pyriform 
sinuses. The larger and more rounded the body the more likely is it to 
lodge in one of the two situations last named. Sharp-pointed bodies are 
more likely to be arrested higher up. 

In the (Esophagus. — Small, smooth bodies once gaining entrance to the 
oesophagus are generally cared for by nature, and no symptoms whatever 
arise. The gullet presents three sites where the caliber is normally 
diminished : the first is at its junction with the pharynx, where the 
forward projection of the cricoid cartilage encroaches on its lumen ; the 
second is at the middle third, opposite the first rib, where the com- 
mencement of the left bronchus crosses it ; and the third corresponds to 
the passage through the diaphragm. Ordinarily the gullet is flattened 
from before backward, so that on section its lumen appears as a trans- 
verse slit, but occasionally it is rounded with the lumen stellate. A 
foreign body may lodge at one of the three sites mentioned or, if large 
enough or rough and uneven, at any point in the tube. Any patho- 
logical condition which interferes with the proper mastication of food 
or with proper swallowing, like external pressure on the food passages 
or cicatricial contraction, favors lodgement of foreign bodies in the 
pharynx and oesophagus. 

Symptoms.— T\iQ symptoms depend on the nature, size, and shape of 
the foreign body and its position after lodgement. Smooth and rounded 
bodies may give no symptoms whatever, and may remain in the pharynx 
a sur^Drisingly long time before they are actually discovered, though the 
patients generally complain of some pain in the throat. More commonly 
there is a sharp, darting pain, increased by attempts at swallowing or 
speaking, from the fact that muscular action drives the body still farther 
into the tissues. The trauma thus inflicted may set up bleeding or may 
700 



FOREIGN BODIES IN THE PHARYNX AND LARYNX. 701 

lead to inflammatory changes, resulting in oedema, nlceration, and abscess, 
but rarely migration or expulsion without supi)uration. Larger bodies in 
the laryngoi:)harynx may cause oedema, or by their size crowd the epi- 
glottis down on the ux)per opening of the larynx, causing dyspnoea and 
even suffocation. There are more or less reflex retching, irritative cough 
with expectoration, and impaired voice. In one case a copper coin 
lodged in the tissues gave symptoms of metallic poisoning. The irri- 
tation causes more or less spasmodic action of the muscles of the food- 
tube. In cases of foreign bodies in the oesophagus these symptoms are 
also present in varying combination, but fluids may pass easily, while 
solids are arrested. 

Tolerance of Foreign Bodies. — Autopsies or surgical explorations often 
reveal foreign bodies whose presence had not been suspected. Foreign 
substances thus buried in the tissues of the pharynx rarely cause any 
serious trouble, but in the oesoi^hagus secondary conditions may ensue 
and prove very dangerous and even fatal. These include abscess, which 
may mixture into the various thoracic tissues, cavities, and tubes, or by 
metastasis set up suppuration in other j^arts of the body, actual per- 
foration of the oesophagus by the foreign body, and the latter' s penetra- 
tion of a large vessel followed by fatal hemorrhage. The foreign sub- 
stance may also penetrate the i)ericardium and pleural cavities, or cause 
caries of the bony spine and laryngeal oedema. Finally, foreign bodies 
may migrate from the initial place of lodgement and be found in the 
most unexpected places. 

Diagnosis. — ^yhen a patient complaining of a sujiposed foreign body 
in the throat is first seen it should immediately be ascertained whether 
or not there is any foreign substance actually present. It may have 
lodged for a time and then escaped, leaving a raw surface, Avhich would 
readilj^ heal with cessation of pain did not the inevitable use of the 
muscles in swallowing and talking keep up more or less irritation. 
Two foreign bodies may have been swallowed, one of which has passed 
on while the other remains. In a very large number of "fish-bone" 
cases no bone will be found. When nothing can be seen with the eye or 
mirror, the throat should be most carefully palpated with the finger, 
and if this reveal nothing, a careful j)robing should be made of the 
pyriform sinuses. For examination in cases of suspected large bodies, 
the patient should lie on the back. The nasopharynx should not be 
overlooked, for a coughing attack may have driven the body up into this 
locality. In the case of foreign bodies in the oesophagus, a soft-rubber 
tube or the ordinary oesophageal bougie will enable the surgeon to locate 
the obstructing body. Metallic substances may be located by the click 
elicited by contact with an instrument of the same material. All in- 
struments used in these manipulations should be well oiled. The use 
of the X-rays in locating bodies in doubtful cases has removed one of 
the obstacles in the way of accurate diagnosis. 



702 DISEASES OF THE LARYNX. 

Treatment. — In cases of foreign bodies witliin easy reach, any forceps 
capable of a firm grasp may be used for removal. When the body is lower 
down, a curved forceps will easily reach the lower pharynx. A change 
of position of the foreign substance by means of a blunt hook is some- 
times necessary before it can be grasped. When there are urgent symp- 
toms from impaired breathing, and immediate removal is not possible, it 
may be necessary to perform tracheotomy, after which the steps requisite 
for the removal of the body can easily be taken and with the greatest 
deliberation. Boluses of soft food can be x^ushed down into the gullet, 
but no such attempt should be made with hard, unyielding masses. For 
these a variety of '' coin-catcher" is pi^eferable ; curettes and snares are 
often serviceable, and external manipulation may assist in removal. 
Sometimes the fiuger offers the best means of removal, and it should be 
carried systematically over the entire throat. In all cases of great in- 
tolerance, and these cases are intolerant par excellence^ it is well to make 
the first inspection without either mirror or tongue- depressor. If more 
prolonged manipulation be necessary, a mild cocaine spray, not over four 

Fig. 277. 




Bond's forceps (Roe's modification). 

per cent, in strength, will relieve much of the irritability. If the site of 
implantation can be made out, boroglyceride may be used topically, or 
inhalations of a drachm of compound tincture of benzoin to a pint of 
boiling water. 

Many foreign substances are removed by the reflex coughing excited 
by their presence, while in other cases the act of vomiting will expel 
the offending mass. This method of relief applies especially to bodies in 
the oesophagus, but it should be remembered that it is inadmissible as a 
therapeutic measure in the case of bodies with sharp points or rough 
angles. In addition to the common emetics, such as mustard, ipecac, 
etc., apomorphine may be hypodermically injected (one-tenth of a grain), 
and repeated in half an hour if the first dose does not act. It is prompt, 
reliable if freshly made from a tablet at the time of using, and causes 
no preceding nausea. Inversion of the body may assist in clearing the 
pharynx, but is useless when the mass is lodged in the oesophagus. 
Digestive ferments have been used in some instances to loosen a mass 
of animal substance. 



FOEEIGX BODIES IX THE PHARYNX AXD LARYNX. 



703 



Various forceps, rings, and sponges have been devised for the removal 
of foreign bodies. Especially' serviceable are the instruments of Fauvel 
and Dawson. For bodies which allow of the j)^ssage of an instrument 
beyond the site of lodgement the bristle probang of Gross is most useful. 
At times the only resource at command is to push the foreign body down 




Fauvel's forceps, antero-posterior view. 



into the stomach. It may be of such a nature that it will pass through 
the stomach and bowels and out through the rectum without further inci- 
dent, or some further surgical i^rocedure, such as opening the abdominal 
cavity, may be necessary. At other times the firm impaction of the body 
in the oesophagus calls for oesophagotomj'. For the details of this opera- 
tion works on general surgery must be consulted. 



704 



DISEASES OF THE LARYNX. 



Fig. 280. 




FOREIGN BODIES IN THE LARYNX AND TRACHEA. 

During the acts of mastication, swallowing, and inspiration in breath- 
:, laughter, etc., various foreign bodies may be drawn into the trachea 
and parts below. Most of these are either pins, 
needles, coins, buttons, or tooth-plates. Fluids, unless 
they be of a caustic nature, do not, as a rule, cause 
any x^ermanent trouble, though there is much mo- 
mentary discomfort. In the vast majority of cases 
the foreign substance comes from 
without, though it is possible for 
vomited matters to be aspirated 
into the air- passages. Leeches 
and intestinal parasites become 
similarly located. Finally, foreign 
bodies may iDcnetrate through the 
cervical tissues or cervical fistulse. 
In children, who have a habit of 
holding all sorts of small bodies 
in the mouth, the accident fre- 
quently happens during sleep. So 
also tooth-plates often slip from 
their jDlaces during sleep and 
lodge in the throat. The advice 
should be most forcibly impressed 
on patients that tooth-iDlates should 
be removed before retiring. Dur- 
ing waking hours the natural sen- 
sitiveness of the pharynx causes 
sufficient reflex action to provoke 
immediate expulsion of a foreign 
substance, or will at once call at- 
tention to its presence, so that 
the proper means of relief can 
immediately be taken. During 
sleep, however, the natural sensi- 
tiveness is somewhat in abeyance, 
hence the greater frequency of 
accidents at this time. Smooth 
round bodies are especially dan- 
Gross's bristle probang. gerous, as they are more apt to 
fall into the eiottis. 




Dawson's flexible for- 
ceps. 



Symptoms. — These naturally depend on the size, shape, nature, motility, 
and position of the offending mass. They are vocal impairmeut, irrita- 
tion, pain, cough, and varying degrees of dyspnoea. Sometimes the 



FOREIGN BODIES IN THE PHARYNX AND LARYNX. 705 

occurrence of a combination of these symptoms may be the first evidence 
that there is something wrong, for cases are on record in which the 
patient was quite unconscious of having swallowed anything. Generally, 
however, the onset of a choking sensation quickly calls attention to the 
accident. The foreign body acting as a direct irritant sets up a spasm 
of the glottis, the dyspnoea being inspiratory. The condition may 
speedily go on to a fatal result if relief be not quickly afforded, or 
the acute symptoms may pass off, the foreign body still remaining in 
position. In the latter case there is a renewal of the seizures from 
time to time, though in the subsequent attacks the symptoms are less 
severe. Inflammation leading to suppuration may be set up, evidenced 
by attacks of cough with blood streaked and purulent sputa, and possi- 
bly septic manifestations. Peas, beans, and similar substances absorb 
moisture and undergo decomposition, though foreign bodies sometimes 
become coated with lymph and calcareous salts, and if not expelled 
may migrate in various directions ; or the foreign substance may, by a 
process of ulceration, free itself and be coughed up, when all symptoms 
cease. Cases are on record, however, in which the foreign body has been 
borne comfortably for many months with surprisingly little disturbance. 
Eecords show that flat buttons and coins are apt to be found in the ven- 
tricles of the larynx, pins, needles, and fisli-bones in the epiglottis, the 
aryepiglottic folds, or the ventricular bands. Pins may lie head down- 
ward and point penetrating, or they may be so embedded as not to show 
the relative i^ositions of head and i)oint. This may result from the fact 
that pins are generally held in the mouth with the point out, or in their 
descent the position may be reversed by an adaptation of their centre of 
gravity. 

Diagnosis. — Inspection with the mirror will often reveal the source of 
the trouble, and if the body be in the larynx, palpation may be of valu- 
able assistance. The possibility of the presence of a foreign body should 
always be borne in mind in examining a patient who has complained for 
some time of laryngeal irritation without apparent cause. The presence 
of the foreign body having been determined, the next step is to find its 
exact location. In case it has passed out of sight, it may lodge low 
down in the trachea, or may have entered a bronchus, more commonly 
the right for anatomical reasons. Careful physical exploration of the 
chest should be made, for if the body be occluding a main bronchus 
there will be a difference of respiratory sounds on the two sides. The 
X-rays are here of great assistance, for with their aid many bodies have 
been successfully located and removed whose exact site would otherwise 
have been merely conjectural. Given the symptoms above described 
with a unilateral bronchitis, the possibility of the accident now under 
consideration should be closely inquired into. 

Frognosls. — In case the body actually enters the larynx, the prognosis 
cannot be otherwise than grave. Mature endeavors to afford relief by 

45 



706 DISEASES OF THE LARYNX. 

expulsion through the route of entrance. If the symptoms be of suf- 
ficient urgency to threaten immediate asphyxia, tracheotomy should at 
once be performed ; but if the initial attack subside, there is time to 
consider the best method of removal. If possible, nature should be 
imitated and an endeavor made to remove the body through the natural 
passages. Bosworth collated sixteen hundred and seventy-one cases in 
which death occurred without operation in 28.6 per cent, and after 
operation in twenty-five per cent. 

In regard to the best course to follow in a given case, guidance may 
be obtained from statistics. The most elaborate list with which the 
writer is acquainted is that prepared by J. O. Eoe.^ These figures are 
of sufficient importance to be quoted somewhat in detail. Out of seven 
hundred and sixty-two cases the foreign body was in the larynx in three 
hundred and twelve and in the trachea in four hundred and fifty 5 of 
the laryngeal cases, cervical incision for removal was made in one hun- 
dred and twenty-four. In this number there were twenty-five laryngoto- 
mies, all successful ; eighty-one tracheotomies, with sixty-five recoveries ; 
ten laryngo-tracheotomies and six thyrotomies, all recoveries ; one by ex- 
ternal incision, nature not stated 5 and one pharyngotomy with a fatal 
result. Out of the remaining one hundred and eighty-eight cases, thirty- 
one were not operated on, and all but three died. There were forty 
spontaneous expulsions, with thirty-eight recoveries, and one hundred 
and one removals by mouth, all recovering, forceps being used in each 
instance. Of the remaining sixteen, all recovered after removal through 
the mouth by various instruments other than forceps. Summary of 
recoveries, 84.9 per cent. 

Of the four hundred and fifty tracheal cases, cervical incision was 
made in two hundred and thirty -nine, with two hundred and one recov- 
eries, — viz., two hundred and twenty-two tracheotomies, nine laryngo- 
tracheotomies with eight recoveries, seven laryngotomies, and one thy- 
rotomy, all recoveries. Of the remaining two hundred and eleven, 
fifty-eight were without operation, and all but two died ; there were one 
hundred and twenty-four spontaneous expulsions, with one hundred and 
twelve recoveries ; fourteen removals with forceps, nine by inversion of 
the patient, two by emesis, one by use of iodine, and one by a blow on 
the back, all recovering ; in two cases oil was used, one recovering. Sum- 
mary of recoveries, seventy-seven per cent. In many instances it was 
found that on opening the trachea the body was spontaneously expelled 
through the opening. 

Treatment. — This resolves itself into spontaneous expulsion through 
natural passages or surgical removal through either natural or artificial 
channels. Under the first heading emetics are to be condemned if the 
body be sharp and impacted, as they may increase the danger of penetra- 

1 Burnett's System, 1893, vol. ii. 



FOREIGN BODIES IN THE PHARYNX AND LARYNX. 707 

tiou, tliough they are useful in relaxing the spasm of the glottis on smooth 
bodies. Coughing is of service only when the body is in the pharynx ; it 
does not, as a rule, assist in laryngeal cases. ^Yhen the foreign substance 
is heavy, inversion is of special service, and should always be tried be- 

FiG. 281. 




Mackenzie's laryngeal forceps, 



fore operating, for thereby the surgeon brings gravity to his aid. Arti- 
ficial digestion of anioial substances has been successfully tried. 

Instruments for Extraction. — If the body be above the cords, earnest 
attemijts should be made to remove it through natural channels. Some- 
times treatment of the inflammatory reaction will lead to a subsidence of 
the swelling, and the body can then be removed, though it may have 
been impossible to effect this result immediately after the accident. 

Fig. 282. 




Cusco's laryngeal forceps. 

Large bodies have been crushed and removed piecemeal. In children it 
is usually necessary to employ a general anaesthetic, but in adults it is 
unnecessary in the majority of cases. Local ansesthesia (cocaine or 
eucaine) must be carefully applied, so as not to excite spasm. 



708 ^ DISEASES OF THE LARYNX. 

As to removal through artificial channels, the principles of procedure 
are as follows. For large angular bodies in the larynx, where movement 
will lacerate the tissues, thyrotomy 5 the only danger is possible impair- 
ment of voice. For small, smooth bodies impacted above the cords, so 
that they can be removed through the opening or pushed up through 
the mouth, incision through the cricothyroid membrane. For impac- 
tion of large bodies in the lower larynx or upper trachea, laryngo- 
tracheotomy. For bodies in the trachea or bronchi, and for all cases in 
children, a high or low tracheotomy, according to the position of the mass 
with reference to the isthmus of the thyroid gland. For bodies in the 
upper larynx so impacted that direct access is required, pharyngotomy 
(lateral or subhyoid). 



INDEX. 



Abscess, brain, otitic, 212-218 
cerebellar, otitic, 217 
cerebral, otitic, 212-217 
extradural, otitic, 201-204 
labyrinth, otitic, 208 
perisinoiis, otitic, 201-204 
retropharyngeal, 485-487 
Adam's apple, 576 
Anaemia, ear in, 140, 220 
Anosmia, 287 
Antrum, maxillary, empyema of, 359-374 

of Highmore, tumors of, 373, 374 
Aphonia, 602 

Aspergillus in the ear, 100-103 
Attic, tympanic, 33 

Auditory canal, anatomy and physiology, 
6-15 
at birth, 9 
cartilage, 14 

ceruminous glands in, 14 
developed, 13 

diffuse otitis externa, 97, 98 
escape of cerumen from, 15 
inflammation, 96 
otitis externa circumscripta, 96, 

97 
otomycosis, 100 

relation of Fallopian canal to, 14 
skin of, 13 
tympanic bone, 9 
vessels and nerves, 14 
nerve, 68-72 
Auricle, anatomy and physiology, 1-5 
arteries and veins, 4 
developed, 2 
embryology, 1, 2 
lymphatics, 4 
nerves, 4 
resonance, 5 
skin, 3 



Boils in the ear, 96, 97 
Brain-abscess, bicameral, 213 
brain-pressure in, 215 
histological seat, 214 
interstitial, 214 
mixed form, 216 
parenchymatous, 214 
treatment, 216 
Bright' s disease, ear in, 170 



Carcinoma of auditory canal, 119 

larynx, 652-660 

pharynx, 523-525 
Cavernous sinus, thrombosis, 211 
Cerumen, 14 
Chorda t\Tiipani, 41 
Chorea of the larynx, 665 
Corti's organ, 66 
Cystomata of the larynx, 651 

of the tonsils, 519 
Cysts, nasal osseous, 342 



Diphtheria, 676-692 
aural, 169 
bacillus, 677 
complications, 682 
culture test, 677 
diagnosis, 682, 683 
etiology, 676 
false, 685 
faucial, 169 

immunization, 689-692 
internal ear in, 220 
intubation, 690-692 
lacunar, 682 
laryngeal, 681 
mixed infection in, 685 
nasal, 169, 296-298, 681 



r09 



710 



INDEX. 



Diphtheria, pathology, 678-680 

predisposition, 678 

sequelae, 682 

symptoms, 680, 681 

toxin, 679 

treatment, 686-692 
Dry mouth, 574 



Ear, diseases of, 96-220 
examination of, '^6-87 
external, see Auricle and Auditory 

canal 
internal, 58 

ampullae, 60, 70 

anaemia, 140, 220 

anatomy and physiology, 58-60 

auditory nerve, 68 

ciliated cells, 67 

cochlea, 61, 63, 72 

Corti's organ, 66 

crista spiralis, 65 

diphtheria, 220 

diseases, 218-220 

ductus cochlearis, 65 

embryology, 58, 59 

endolymph, 71 

hallucinations of hearing, 220 

in leukaemia, 219 

in submarine laborers, 219 

labyrinth, 58, 60 

membrana reticularis, 67 

membrane of Reissner, 64 

modiolus, 61 

otoliths, 71 

perilymph, 71 

psychic deafness, 220 

relation of, to middle ear, 73-75 

sacculi, 69 

scalae, 62 

semicircular canals, 62, 69 

syphilis, 219 

tinnitus aurium, 220 

traumatism, 218 

tubercle, 219 

vestibule, 60 
middle, see Tympanic cavity 
specula, 78 
syringing, 81 
vertigo, 131 

in chronic purulent otitis media, 
155 



Ear- vertigo, operation for, 156, 157 
pilocarpine in, 157 
surgical treatment, 150 
Ecchondrosis of the nasal septum, 404- 

408 
Empyema of the maxillary antrum, 359- 
374 
diagnosis, 364-367 
etiology, 359, 360 
pathology, 360, 361 
prognosis, 367, 368 
symptoms, 360-364 
treatment, 368-373 
of the sphenoidal sinuses, 382-386 
Endocarditis, ear in, 140 
Endolymphatic space, 150-152 - 
Epiglottis, diseases of, 620-622 
enlargement of, 621, 622 ^ 
Epilepsy from ear disease, 140 
Epistaxis, 265-269 
diagnosis, 266 
etiology, 265 
plugging nares, 268 
prognosis, 267 
prophylaxis, 269 
symptoms, 266 
treatment, 267-269 
Ethmoiditis, suppurative, 386-390 
Eustachian tube, anatomy and physiol- 
ogy, 47-54 
blood-vessels and nerves, 53 
bony portion, 48 
cartilaginous portion, 48 
catheter, 82 

inner pterygoid muscle, 52 
mucous membrane, 52 
tensor palati, 50 
tonsilla pharyngea, 53 
Exostosis of the auditory canal, 116 

of the nasal septum, 404-408 
Extradural abscess, otitic, 202 
suppuration, otitic, 201, 202 



Facial nerve, course of, 40 

paralysis, otitic, 171, 194-197 

Furunculosis of the ear, 96 
of the nose, 280 



Glottis, spasm of, in adults, 662-665 



INDEX. 



711 



H 

Hsematoma, nasal septum, 410, 411 
Hallucinations of hearing, 220 
Hay fever, 259-264 

asthmatic attacks, 264 
diagnosis, 262 
etiology. 260 
pathology, 260 
prognosis, 262 
symptoms, 261 
treatment, 262-264 
Hearing, bone-conduction of sound, 88 
normal, 88 

simulated deafness, 95 
tests of, 88-95 
tuning-fork, 89, 90 
Hyperosmia, 288, 289 
Hysterical deafness, 140 

I 

Incus, 29, 30 

Internal ear, 58-75 

Intubation of the larynx, 690-692 



Jacobson's nerve, 42 



Labyrinth, 60-75 

abscess, otitic, 203 
Laryngeal cartilages, chondritis, 622-624 
perichondritis, 622-624 

image, 595 

vertigo, 673-675 
Laryngitis, aphonia in, 602 

atrophic, 615-617 

catarrhal, acute, 508 

in children, 602-605 
chronic, 612-615 

croupous, 605-607 

hemorrhagic, 600 

nodular, 617, 618 

oedematous, 608-610 

phlegmonous, acute, 607, 608 

subglottic oedema, 600 

tubercular, 625-640 
Larynx, amemia, 618 

anaesthesia, 661 

pnatomy, 576-588 

arteries, 584, 585 

carcinoma, 653-660 



Larynx, cartilages, 576-580 
chorea, 665 
cystomata, 651 
deformities, 610 
diseases, 576 
dysphonia spastica, 666 
electric laryngoscope, 593 

transillumination, 594 
eversion of ventricle, 652 
examination, 589-596 
exanthamata, 693-697 
fibromata, 651 
foreign bodies in, 704-708 
fractures, 610, 611 
hemorrhage, 618-620 
hypersemia, 618 
hyperaesthesia, 661 
inflammations, acute, 598 

chronic, 612-624 
influenza, 699 
injuries, 610 
ligaments, 580-584 
lupus, 646, 647 
malarial fevers, 698 
measles, 695 
muscles, 584-588 
nerves, 586 
neuroses, 661-675 
oedema, 608-610 
pain in tubercular, 631 
paralysis, 666-668 

abductors, 671, 672 

adductors, 670, 671 

inferior laryngeal nerve, 668 

physiology, 596, 597 

recurrent, 669 

special, 668-675 

superior laryngeal nerve, 668 

tensors of vocal cords, 672, 673 
rima glottidis, 582 
rotheln, 696 
sarcoma, 652, 653 
scarlatina, 693 
spasm of, in children, 662 
syphilis, 641-646 
tuberculosis, 625-640 
tumors, 648 

benign, 648 

malignant, 652-660 
typhoid fever, 697 
typhus fever, 698 
ulceration, tubercular, 630 



712 



INDEX. 



Larynx, varicella, 697 

variola, 696 

vascular abnormalities, 618-620 

ventricles, 583 
Leptothrix, 493-495 
Lingual tonsil, inflammation of, 554-556 

varix, 556, 557 

veins, enlarged, 556, 557 
Lupus of larynx, 646, 647 

nose, 280-283 

pharynx, 501-504 
Luschka's tonsil, 53 

M 

Malleo-incudal joint, 30 
Malleus, 26 

ligaments, 28 
Massage, pueumo-, of ear, 79, 145-147 
Mastoid, acute empyema, 171-174 
anatomy and physiology, 54-57 
antrum, 55 
Mastoiditis, acute, treatment, 168 
chronic, 190, 191 
hysterical, 141 

spontaneous perforation of medial 
plate, 167 
Membrana tympani, anatomy and physi- 
ology, 16-23 
blood-vessels, 23 
color, 17 

dermoid layer, 16 
flaccid portion, 17, 19, 179 
folds, 19, 22 
geometric divisions, 20 
inclinations, 18 
inflammation, acute, 121 

chronic, 122 
injuries, 123 
internal layer, 22 
lustre, 18 

membrana propria, 21 
middle layer, 21 
morbid growths, 126 
mucous layer, 22 
outer surface, 16 
pouches, 23, 34, 35 
pyramid of light, 20 
segment of Rivinus, 16 
Meniere's disease, 150-154 
Meningitis, acute serous, 218 

otitic, 217, 218 
Middle ear, 25 



Mumps, ear in, 139 
Mycosis, aural, 100-103 
leptothricea, 492-495 

N 

Nasal affections in acute infectious dis- 
eases, 269-272 

influenza, 271 

scarlatina, 270 

typhoid fever, 270 
septum, deflection, 391 

hsematoma, 410, 411 
tumors, 331-349 

bony, 343, 344 

cartilaginous, 344, 345 

fibrous polypi, 339, 340 ^ 

malignant, 345-349 

mucous polypi, 331-339 

osseous cysts, 342, 343 

papillary, 340, 341 

vascular, 341, 342 
Nasopharyngitis, chronic deafness, 425- 

427 
Nasopharynx, anatomy, 221, 240-243 
benignant tumors, 445-455 
digital examination, 249 
Eustachian orifices, 248 
examination, 245-249 
general description, 242 
histology, 243 
Luschka's tonsil, 242, 248 
malignant tumors, 455-457 
muscles of soft palate, 241 
pharyngeal tonsil, 243 
posterior nares, 247 
retronasal cartilaginous tumors, 454, 
455 

fibromatous tumors, 453-455 
rhinoscopy, 246 
Rosenmiiller's fossa, 242 
syphilis, 458-461 
tuberculosis, 461, 462 
tumors, 445-457 
turbinals, 248 
Nephritis, effects of, on internal ear, 138 
Neuroses of the larynx, 661-675 

pharynx, 526-530 
Nose, accessory sinuses, 231 
anatomy, 221 

antrum of Highmore, 232, 233 
arteries, 223, 228 
cavity, 226 



INDEX. 



713 



Nose, circulation of mucous membrane, 
235 
congenital syphilis, 354, 355 
cutaneous diseases, 280-287 
deformity, 289, 290 
diseases of 221-413 
disorders of sense of smell, 287-289 
ethmoid region, 231 
examination of, 244, 245 
external, 222 

muscles, 223 
foreign bodies in, 273-279 

animal parasites, 278 

diagnosis, 274 

maggots, 276 

prognosis, 274 

rhinoliths, 275 

symptoms, 273 

treatment, 275 
fractures, 290-293 
furunculosis, 280 
in fevers, 226 
infundibulum, 230 
lateral wall, 227, 230 
lupus, 280-283 
meatuses, 229, 230 
mucous membrane, 228, 233-238 
nasal reflexes, 240 
nerves of mucous membrane, 228 
olfactory function, 239 
region, 237, 238 
supporting cells, 236 
physiology, 238, 239 
respiratory function, 238 
rhinoscleroma, 283-287 
rhinoscopy, 245 

section of mucous membrane, 234 
septum, 224 
sneezing, 240 
sphenoid region, 232 
syphilis, 349-356 
tuberculosis, 356-358 
tubular mucous glands, 235 
turbinates, 227 
veins, 228 



CEdema of the larynx, 608-610 

CEsophagus, foreign bodies in, /"OO 

Oidium albicans, 491, 492 

Otic ganglion, 42 

Otitis media, catarrhal, acute, 127-129 



Otitis media, catarrhal, chronic, 130-138 
adenoid gro\^'ths, 135 
ear-vertigo, 131 
endolymph, 150 
Eustachian tube, 135 
inflation, 136 
malignant growths in 

nasopharynx, 137 
membranatympani, 133, 

154 
nephritis in, 138 
objective noises in the 

ear, 137, 138 
perilymph, 150 
pharynx, 134 
sclerosis, 134 
sequela?, 138-141 
treatment, 142-150 
velum, 134 
purulent, acute, 158-175 
bacteriology, 158 
Bright' s disease, 170 
case, 164 

diphtheria, faucial, na- 
sal, and aural, 169 
facial paralysis, 171 
mastoiditis consecutive, 

163 
paracentesis, 162, 165 
spontaneous perforation 

of medial plate, 167 
treatment, 160-167 
tuberculosis, 159 
chronic, 175-193 

cholesteatoma, 197 

ear-vertigo, 155 

facial paralysis, 194-197 

granulations, 183 

in young children, 191- 

193 
mastoiditis, chronic, 190 
ossiculectomy, 189 
polypi, 183 
polypus hook, 186 

snare, 185 
sequelae, 194-197 
Stacke's operation, 197, 

198 
treatment, 180-183 
tweezer forceps, 188 
without external symp- 
toms, 191-193 



714 



INDEX. 



Otomycosis, 100-103 
Otoscope, hand, 76 
Siegle's, 78, 79 
Ozsena, 322-330 



Palate, soft, anatomy, 465, 466 
lupus, 502 
physiology, 466, 467 
Perilymphatic space, 150-152 
Perisinous abscesses, 203 

treatment, 203, 204 
Pharyngeal mycosis, 492 

neuroses, motor, 527-530 

sensory, 526, 527 
tonsil, hypertrophy, 428-444 
diagnosis, 437, 438 . 
etiology, 428, 429 
pathology, 429-433 
prognosis, 438, 439 
symptoms, 433-437 
treatment, 439-444 
Pharyngitis, acute catarrhal, 474-476 
follicular, chronic, 481-485 
granulosa, 483 
membranous, 477, 478 

chronic, 480, 481 
phlegmonous, acute, 476, 477 
Pharyngocele, 471 
Pharynx, adenoma, 518 
anatomy, 463^66 
angioma, 518 
carcinoma, 523-525 
deformities, 471-473 
development, 465 
diabetic ulcerations, 514, 515 
erysipelas, 511, 512 
examination, 467-469 
exanthemata, 693-697 
faucial pillars, defective, 471 
fibroma, 518 

foreign bodies in, 700-704 
hemorrhage, 489-491 
herpes, 512-514 
inflammations, acute, 474-478 

chronic, 479-487 
influenza, 699 
lipoma, 518 
lupus, 501-504 
malarial fevers, 698 
malformations, 470, 471 
malignant growths, 520-525 



Php- measles, 695 

-^ous patch, 505 

neuroses, 526-530 

papilloma, 516 

parasitic affections, 491-495 

pemphigus, 514 

physiology, 466, 467 

rotheln, 696 

sarcoma, 520, 521 

scarlatina, 693 

syphilis, 504-511 
congenital, 510 

syphilitic erythema, 505 

tuberculosis, 496-700 

tumors, 516-525 
benign, 516-520 

typhoid fever, 697 

typhus fever, 698 

varicella, 697 

variola, 696 

vascular anomalies, 488^91 
Phlebitis, otitic, 205-212 
Pneumatic massage of the ear, 147 
Politzer's inflation, 86, 87 
Pyaemia, otitic, 205-212 



Quinine, effects of, on ear, 141 
Quinsy, 551-554 



Eetropharyngeal abscess, 485-487 
Ehinitis, acute, 250-259 

blennorrhoica, 258 

causes, chemical, 252 
exciting, 251 

characteristics, anatomical and 
pathological, 250 

complications, 254 

diagnosis, 255 

irrigation of nose, 258 

prognosis, 256 

prophylaxis, 256, 259 

symptomatic, 252 

rhinoscopic appearances, 253 
atrophic, 322-330 

diagnosis, 326, 327 

electrolysis, 329 

ozsena bacillus, 325 

pathology, 322-324 

symptoms, 325 

treatment, 327-330 



INDEX. 



715 



Rhinitis, chronic, simple, 299-3 
diphtheritic, 296-298 
fibrinous, 294-296 
hypertrophic, 314-322 
diagnosis, 317 
pathology, 314, 315 
symptoms, 315-317 
treatment, 318-322 
intumescent, 304-313 
complications, 312 
diagnosis, 307 
pathology, 304-306 
prognosis, 307 
symptoms, 304-307 
treatment, 307, 308 
local, 308-312 
Ehinoliths, 275 
Rhinopharyngitis, acute, 413^17 

chronic, 417-425 
Rhinoscleroma, 283-287 

bacillus of, 286 
Rosenmiiller's fossa, 242 



Salicylic acid, effects of, on ear, 141 
Sarcoma of larynx, 652, 653 

of pharynx, 520, 521 
Semicircular canals, 60, 63 
Senile changes in ear, 140 
Septum, nasal, diseases, 391 
abscess, 411, 412 
deflection, 391 
ecchondrosis, 404-408 
exostosis, 404-408 
perforation, 408-410 
nasi, 224 

arteries, 225 
cartilage, 225 
nerves, 225 
Sinus, cerebral, thrombosis, 205-211 
diagnosis, 210 
treatment, 206-211 
frontal, inflammation, 375-382 
diagnosis, 378-380 
pathology, 375, 376 
symptoms, 376-378 
treatment, 380-382 
Sinuses, accessory, of nose, inflammation, 
375-390 
sphenoidal, empyema, 382-386 
Stacke's operation, 197, 198 
Stapes, or stirrup, 30 



Stapes, ankylosis of, 140, 141 

oval window, 31 
Syphilis of the internal ear, 219 
larynx, 641-646 
nasopharynx, 458-461 
nose, 349 

congenital, 354, 355 
pathology, 349, 350 
symptoms, 350 
pharynx, 504-511 
Syringing, ear, 81 



Tabes dorsalis, ear in, 139 
Tegmen tympani, 32 
Temporal bone, 10-13 

annulus tympanicus, 7 
base of infant's skull, 8 
of infant, 6, 7 
surface, inner, 11 
outer, 10 
under, 12 
tympanic spines, 8 
Tensor palati muscle, 50 
Thrombosis, otitic, 205-212 
Thrush, 491, 492 

Thyroid gland, effect of, on ear, 140 
Tinnitus aurium, 220 
Tonsil, lingual, inflammation, 554-556 
pharyngeal, hypertrophy, 428-444 
Tonsillitis, acute catarrhal, 539, 540 
croupous, 547-550 
lacunar, 540-543 
parenchymatous, 543-547 
albuminuric, 550 
chronic lacunar, 557, 558 

parenchymatous, 558-570 
gangrenous, 551 
Tonsils, anatomy, 536-539 
diseases of, 536-575 

abscess, chronic encysted, 570 
bony growths, 574 
calculi, 573 

cartilaginous growths, 574 
cysts, 519 
foreign bodies, 573 
inflammation, acute circumton- 
sillar, 551-554 
chronic, 557-575 
lingual tonsil, chronic enlarge- 
ment of, 570-572 
polypoid hypertrophy, 572, 573 



716 



INDEX. 



Tonsils, diseases of, treatment, 558-575 

xerostomia, 574 
Trachea, foreign bodies in, 704-708 
Tuberculosis of the internal ear, 219 
larynx, 625-640 
nasopharynx, 461, 462 
nose, 356-358 
pharynx, 496-501 
uvula, 500 
Tumors, nasal, 331-349 
nasopharynx, 445-457 
benignant, 445-455 
malignant, 455-457 
pharynx, gummy, 505, 506 
retronasal, benign, rare, 454, 455 
cartilaginous, 454, 455 
fibromucous, 453, 454 
fibrous, 445-453 
Tuning-fork, 89, 90 
Turbinated bones, 227 
Tympana, inflation of, 83, 84, 85 
Tympanic bone, 9 

cavity, anatomy and physiology, 24- 
46 
attic, 33 

axis-ligament, 28 
blood-vessels, 43 
chorda tympani nerve, 41 
embryology, 24 
facial nerve, 40 
incus, 29, 30 

malleo-incudal joint, 30, 33 
malleus, 26 
middle ear, 25 

muscular accommodation, 46 
ossicles, 25 
otic ganglion, 42 



Tympanic cavity, physiology, 43 

recessus epitympanicus, 33 
round window, 44 
stapedius muscle, 37, 38 
stapes, 30, 31 
tegmen, 32 

tensor tympani muscle, 38 
walls, 34, 36, 39, 40 
nerve, 42 

Tympanum, 32 

Typhoid fever, ear in, 127 
larynx in, 697 
nose in, 270 
pharynx in, 697 

U 

Uvula, diseases of, 531-536 
anomalies, 531 
hsematoma, 531 
hypertrophy, 532-536 
malformations, 531 
uvulitis, acute, 532 

chronic, 532 
uvulotomy, 534-536 



Varix, lingual, 556, 557 
Vertigo, aural, 131 

laryngeal, 673-675 
Vestibule, internal ear, 60 
Vocal cords, paralyses of, 668-675 



X 



Xerostomia, 574 



Zonae, cochlea, 65 



THE END. 



